Autism Screening Broadway Clinic QI project 2011-2012 Arash Salavitabar, Erin Paul, Anna Hays, Joe Grillo, Uchechi Azubuine, Lacy-Ann Landell, Daniel Stephens, Kristal Woldu, Michael Goldman, Emily Whitesel, Lindsay McGann, Lisa Lavikoff Kurz, Robbie Majzner, Lisa McReynolds, Rakhee Bowker Annika Hofstetter, Laura Robbins-Milne, Heidi Beutler, John Rausch, Mariellen Lane, Nan Salamon, Renie Eis Ceila Mendez, Blanca Cordero, Reyna, Felipe Joaquin Evelyn Reyes, Iriada Torres, Kenya Rittenburg, Carlos Sepulveda , Tene Jones, Conchita Laurencio Haydee Bayon, Becky, Sally Ortiz The Broadway Clinic’s Project was on Autism Screening MA: Ceila, Blanca, Felipe and Reyna PFA: Evelyn, Ilriada, Kenya, Carlos and Conchita RN: Haydee, Sally, Becky

AIM Statement Broadway Clinic aims to implement standardized autism spectrum disorder screening using the Modified Checklist for Autism in Toddlers (M-CHAT) for at least 50% of patients at their 18 and 24 month visits. We wanted to focus on development, looking at our rates of developmental screening and EI referrals., specifically focusing on identifying gaps around early diagnosis for autism Therefore, our aim was to implement …

Developmental Surveillance “Early Identification of developmental disorders is critical to the well-being of children and their families” - AAP Missed Opportunities: Estimated 12-16% of children <3 years have delays, yet EI serves only ~2% CDC estimate only 50% children with development/behavioral disability are identified prior to entering school Why was this project important to us? As we all know as pediatricians, and as the AAP clearly states: “Early Idenficiation of developmental disorders is critical to the well-being of children and their families” In addition, we know that there are missed opportunities for early diagnosis and early intervention. EI serves only a fraction NATIONAL AVERAGES OF DEVELOPMENTAL DELAY PER RECENT COCHRANE REVIEW IN PRESCHOOL CHILDREN 2 -4.5 years: Speech and Language delay: Prevalence 5-8% Language delay: 2.3 -19% Untreated speech and language delay in preschool children has shown variable persistence rates, most in the 40% to 60%. The Center for Disease Control (CDC) reports that 17% of children have a developmental or behavioral disability such as autism, yet less than half of the children are identified before entering school. This delay causes children to miss important intervention opportunities.”

Autism Screening Neurodevelopmental disability appearing before age 3 Prevalence 1 in 150 Difficulties in: Verbal and Non-verbal communication Social Interactions Play Activities Autism as we know, is a neurodevelopmental disability, appearing before age 3 The reports of it’s prevlance are varied, but around 1:150 – something that pediatrians in the community will see Autism is a complex diagnosis (which we will not get into here), but presents as some involvement in: Gesturing with noises Peek a book Play activities: Pretend play (as well as dressing in princess outfits)

AAP Recommendations Informal Developmental Surveillance at all well child visits Formal developmental screening at 9, 18 and 24 months Standardized autism screening at 18 and 24 months, or with any parental concern Our project also stemmed from the AAP recommendations around developmental screening -we aren’t doing formal screening, so our concern was that we are missing kids with autism

M-CHAT No one tool has been shown to identify all children: Denver, the PEDS, Ages and Stages Questionnaire Why the M-CHAT? Accessible: Translated into 20+ languages Easy to Use Validated in primary care settings Sensitivity 0.85, Specificity 0.93 FREE! In our project then, we needed to chose a formal screening tool to help us with our goals M-CHAT: The Modified Checklist for Autism in Toddlers is a free, download-able, validated screening tool developed by Robins et al. **Shown to work – in identifying children not otherwise found in primary care settings

It is a 23 question parental survey about a child’s social, verbal and emotional development Scoring is based on number of risk items failed. Any three items warrants referral to a specialist Two “critical” items failed-

Process: The M-CHAT questionnaires will be distributed by the MAs, reviewed and scored during the patient encounter. The baseline rate of standardized autism screening is 0%. Our aim will be to achieve a 50% completion rate. Outcome measures include a percent change in both early intervention and audiology referrals. The rate of early intervention acceptance should also be studied since earlier referral secondary to M-CHAT screening may or may not lead to more services for patients.

Baseline Development Screening Developmental Screening Language Screening 17-20 mo 40/40 37/40 100% 92.5% 22-30 mo 39/40 97.5% To look at baseline developmental screening data, we did an initial chart review, looking at 40 charts in each of these age groupsl We found that we did quite well, >90% screening rate for any developmental screening as well as language specific screening

PDSA Cycles PDSA Cycle 1: Is the M-CHAT Doable? Provider Based Intervention to determine feasibility Found parents able to complete Found providers able to grade Transparencies English and Spanish PDSA Cycle 2: Can the M-CHAT be done as a pre-Screening? Incorporate the MAs 3 cycles Importance in PDSA cycles to start with a small sample, prove that we are able to complete the intervention before generalizing it to the entire practice.

Rate of M-CHAT Distribution 3 cycles to increase distribution  MCHAT as prescreening tool At each cycle, we worked with the Mas to incorporate the MCHAT better into their work flow Interventions included addressing issues: -color coding of sheet -education about autism screening for a greater buy-in Went from 10%16%  34% (18-30 months) (did double with each cycle, though not quite at goal of 50%) Measured based on MCHATs left in exam room – Likely a HIGHER value (I have several MCHATs on the floor of my room at home that were not included in this final count)

Final Data After we implemented the MCHAT form, we wanted to then see if we had made a difference in our rates of EI referral. Evaluated Data from March 2011 and then from March 2012 (after implementation of MCHAT screening) Total patients seen in those months essentially identical: 107 vs 100 (in age group of 18-30months) We evaluated our EI referral rates before and after the initiation of the MCHAT screening Our numbers of patients with identified delay stayed the same (24 vs 22%) %Total EI referrals (23 vs 21%) Maybe slight bump in new EI referrals, but very slight (6 vs 9%) Slight decrease in Audiology referrals (7 vs 4) Also the OVERALL:TOTAL: % of patients with language delay with new or pre-existing referrals : 96% vs 95%

Conclusion: Lessons Learned Autism Screening and the M-CHAT: Feasible Survey of providers: Doesn’t increase provider time Easy to interpret Sustainable? Is this something to continue? Doesn’t appear to increase our rates of EI referral Spread: Have M-CHAT available to be used MCHAT transparency in English and Spanish in exam rooms Sustainable: Didn’t change management or identification in our small sample size. Appears that what we have in our ambulatory note is quite good! Again from our sample size it appears to show that there is no need for additional FORMAL screening. Interesting piece – given AAP recommendations for FORMAL screening beyond our typical developmental surveillance, instead of unilaterally taking their recommendations and implementing them at all sites, our project showed that it may not be in fact necessary. Not able to speak to whether or not we were referring Younger after M-CHAT intervention

Other interventions at Broadway Development Guide! Outpatient handbook Community Peds Website Development Guide: -every wonder what Harriet meant by “Raspberries” or how to ask if a child understands Prepositions? We sat down an asked her. All your questions will be answered. Hoping to include it one the community peds website or the outpatient book whenever that gets off the ground. Gives a guide around how to discuss these issues with the parents, appropriate “probe” questions

EI form now available on Eclipsys in EZVAC! Reduces yet another barrier to EI referrals

Thank You Broadway Clinic! Mariellen Lane Laura Robbins-Milne Celia, Reyna, Blanca, Felipe MAs:

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