Effect of a Computer-Based Decision Support Intervention on Autism Spectrum Disorder Screening in Pediatric Primary
Stephen M Downs1,2, Nerissa S Bauer3, Chandan Saha4
1Division of Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis.
Insights
Computer automation significantly improved autism spectrum disorder (ASD) screening rates in pediatric clinics. However, physician follow-up on positive ASD screening results requires further improvement.
Area of Science:
- Pediatric primary care
- Clinical decision support systems
- Autism Spectrum Disorder (ASD) screening
Background:
- Universal early screening for ASD is recommended but not consistently performed in primary care.
- Current screening practices often lack routine implementation, leading to missed opportunities for early diagnosis and intervention.
Purpose of the Study:
- To evaluate if computer-automated screening and decision support can enhance ASD screening rates in pediatric primary care.
- To assess the impact of integrating an ASD screening module into existing electronic health record systems.
Main Methods:
- A cluster randomized clinical trial involving 274 children aged 18-24 months in urban pediatric clinics.
- Intervention clinics utilized a decision support system (CHICA) with an integrated ASD screening module.
- Control clinics followed standard screening procedures.
Main Results:
- Screening rates in intervention clinics increased from 0% to 100% within 24 months, while control clinics showed no significant increase (15.3%).
- Positive screening results occurred in 27.0% of children screened by the system.
- Physician response to positive screening results within the system was documented in 57.0% of cases.
Conclusions:
- Computer automation integrated with clinical workflow and EHRs effectively increases ASD screening rates.
- Physician follow-up on positive ASD screening results remains a challenge, indicating a need for automated follow-up processes.
Importance:
Universal early screening for autism spectrum disorder (ASD) is recommended but not routinely performed.
Objective:
To determine whether computer-automated screening and clinical decision support can improve ASD screening rates in pediatric primary care practices.
Design, Setting, And Participants:
This cluster randomized clinical trial, conducted between November 16, 2010, and November 21, 2012, compared ASD screening rates among a random sample of 274 children aged 18 to 24 months in urban pediatric clinics of an inner-city county hospital system with or without an ASD screening module built into an existing decision support software system. Statistical analyses were conducted from February 6, 2017, to June 1, 2018.
Interventions:
Four clinics were matched in pairs based on patient volume and race/ethnicity, then randomized within pairs. Decision support with the Child Health Improvement Through Computer Automation system (CHICA) was integrated with workflow and with the electronic health record in intervention clinics.
Main Outcomes And Measures:
The main outcome was screening rates among children aged 18 to 24 months. Because the intervention was discontinued among children aged 18 months at the request of the participating clinics, only results for those aged 24 months were collected and analyzed. Rates of positive screening results, clinicians' response rates to screening results in the computer system, and new cases of ASD identified were also measured. Main results were controlled for race/ethnicity and intracluster correlation.
Results:
Two clinics were randomized to receive the intervention, and 2 served as controls. Records from 274 children (101 girls, 162 boys, and 11 missing information on sex; age range, 23-30 months) were reviewed (138 in the intervention clinics and 136 in the control clinics). Of 263 children, 242 (92.0%) were enrolled in Medicaid, 138 (52.5%) were African American, and 96 (36.5%) were Hispanic. Screening rates in the intervention clinics increased from 0% (95% CI, 0%-5.5%) at baseline to 68.4% (13 of 19) (95% CI, 43.4%-87.4%) in 6 months and to 100% (18 of 18) (95% CI, 81.5%-100%) in 24 months. Control clinics had no significant increase in screening rates (baseline, 7 of 64 children [10.9%]; 6-24 months after the intervention, 11 of 72 children [15.3%]; P = .46). Screening results were positive for 265 of 980 children (27.0%) screened by CHICA during the study period. Among the 265 patients with positive screening results, physicians indicated any response in CHICA in 151 (57.0%). Two children in the intervention group received a new diagnosis of ASD within the time frame of the study.
Conclusions And Relevance:
The findings suggest that computer automation, when integrated with clinical workflow and the electronic health record, increases screening of children for ASD, but follow-up by physicians is still flawed. Automation of the subsequent workup is still needed.
Trial Registration:
ClinicalTrials.gov identifier: NCT01612897.
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