1. 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

2. 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 …

3. 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 years:
Speech and Language delay: Prevalence 5-8%
Language delay: %
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.”

4. 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)

5. 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

6. 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

7. 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-

8. 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.

9. 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

10. 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.

11. 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)

12. 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%

13. 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

14. 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

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

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

17. References
Management of Children with Autism Spectrum Disorders. AAP. Pediatrics. 2007; 120:
Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. AAP. Pediatrics. 2006; 118:
Robins et al. M-Chat: an initial investigation in the early detection of autism and PDD. J Autism Dev Disord. 2001; 31:
Pinto-Martin et al. Screening strategies for autism spectrum disorders in pediatric primary care. J Dev Behav Pediatr :
Glascoe et al. Can a broadband developmental-behavioral screening test identify children likely to have ASD? Clin Pediatr (Phila) :
Screening for ASD in primary care settings. Robins DL. Autism. 12:
The M-CHAT: a follow-up study investigating the early detection of ASDs. Kleinman et al. J Autism Dev Disord :
Early screening for ASDs: update on the M-CHAT and other measures. J Dev Behav Pediatr. Robins DL. And Dumont-Mathieu TM S111-9.
Guidelines for Early Identification, Screening and Clinical Management of Children with ASDs. Greenspan et al Pediatrics. 121:
Early Autism Detection: Are we ready for routine screening? Al-Qabandi et al. Pediatrics. 128 e
The Each Child Study: systematic screening for ASDs in a pediatric setting, Miller et al, Pediatrics. 127:
Identification and Evaluation of Children with Autism Spectrum Disorders. Johnson et al. Pediatrics :
Developmental Surveillance and Screening of Infants and Young Children Committee on Children with Disabilities. AAP. Pediatrics 2001; 108:
Developmental Screening in Early Childhood Systems. Summary Report. AAP. Healthy Child Care America. March 2009