Reconsidering Screening in Primary CareReconsidering Screening in Primary Care https://pediatricsnationwide.org/wp-content/uploads/2021/09/periodicity_schedule_Page-1_color-1024x683.jpg 1024 683 Jeb Phillips Jeb Phillips https://pediatricsnationwide.org/wp-content/uploads/2021/03/Jeb-Phillips.jpg
- October 06, 2021
- Jeb Phillips
Screenings are an important part of preventive care, but the growing list of recommendations is daunting. How do we prioritize the limited time we have with patients and families?
There are 32 well-child primary care visits recommended by the American Academy of Pediatrics in its Bright Futures “Periodicity Schedule.” The first is prenatal, the last happens at 21 years old. During these brief visits, pediatricians need to address a family’s concerns, provide counseling, and, depending on the visit, screen for many different conditions, such as visual impairment, obesity, hypertension, elevated lipid levels, or depression.
The number of evidence-based screenings can be daunting to consider and feel impossible to complete.
“I feel guilty when I look at this list,” says Jill Neff, DO, the only independent pediatrician in rural Jackson County, Ohio, and someone who is well known for her commitment to her patients. “I’m doing the best that I can, but I’m the nurse and the doctor. Including me, there are two full-time people in my office. How am I supposed to find the time to do all of this if there are six kids in my waiting room with ear infections?”
It’s a common concern among primary care providers, and it’s often paired with this one: “If a child does screen positive for a condition, how can I connect them to the services they need?”
There are no easy answers, but over the last several years, a number of organizations and physicians have wrestled with these questions. Among the most recent efforts, this summer clinicians and researchers from Nationwide Children’s Hospital helped lead the publication of a multiple-study supplement in Pediatrics, collectively called “Methods for Assessing the Impact of Screening in Childhood on Health Outcomes.”
The supplement came from a meeting organized by the National Institutes of Health’s Office of Disease Prevention to identify gaps in research needed to help clinicians prioritize the delivery of screening services to evaluate the long-term impact of screening on health and development.
Kelly Kelleher, MD, vice president of Community Health at Nationwide Children’s, acknowledged the benefits of screening but called the study he was the senior author on “the most pessimistic one we’ve published” because it showed that inconsistent screening with inadequate follow up quickly takes away any benefit. (It was the first article in the publication because of the challenges it articulated.)
Alex Kemper, MD, division chief of Primary Care Pediatrics at Nationwide Children’s and an author on several of the studies, said he continues to believe screening is a “core component of the preventive care we do for children.”
Those sentiments aren’t in conflict, they say. Screening is important, and it’s also difficult — particularly when considering the time pressure in primary care and everything that must happen for a screening to be effective.
So how can we do better?
The Justification for Screening
If a condition is an important health problem; if it has a latent or early symptomatic stage that may not be obvious but can be identified; if there’s a validated tool for identification; if patients who have the condition can be treated; if earlier treatment is better than waiting; if screening and early treatment do not lead to significant harm; and if there is not too great a cost. . .then screening is indicated.
Those are the basic principles laid down in a landmark 1968 international publication and they still hold, says Dr. Kemper. The best example of it working in practice is with newborns. The core newborn screening panel can help identify 35 conditions (or significantly more in some states). Unlike the screening that happens in primary care, public health agencies have an active role in conducting the screening and providing follow-up care.
Other screenings are more complicated, in part because of knowledge gaps about how they can be effective and efficient in the primary care practice setting given the limited time of an appointment, says Dr. Kelleher.
On the provider side, someone needs to be educated on how to administer a screen, on how to interpret the results, on how to talk to the families about the results if there is a positive screen. There’s staff turnover. Billing for screening can be confusing. And there is always time pressure in the visits.
– Heather Maciejewski, manager, Center for Clinical Excellence, Partners For Kids
Guidance like the kind in AAP’s Bright Futures is the closest we have, says Joe Hagan, MD, the long-time co-editor of Bright Futures, clinical professor at the Larner College of Medicine at the University of Vermont and pediatric primary care provider. There are countless screening and preventive care recommendations from many sources, he says. Beginning in the mid-1990s, Bright Futures attempted to consolidate the best ones. Then in 2003, recognizing the research gap that existed for much of pediatric primary care, Bright Futures contributors started making a special effort to ensure the recommendations were evidence-informed.
Dr. Hagan has helped lead that effort. Dr. Kemper is an evidence consultant for Bright Futures and a past member of the United States Preventive Services Task Force, which issues opinions and statements on the evidence underlying preventive care.
The current periodicity schedule, last updated in March 2021, is the result of that work. Some of the assessments are nearly automatic parts of well child primary care visits and have been for decades, such as height and weight measurements. Those should then be used to screen for obesity using body mass index, starting at 2 years of age, according to Bright Futures.
Others, including depression screening in adolescence, are comparatively new. Insurance claims data and surveys from Partners For Kids®, Nationwide Children’s accountable care organization, suggest that at best, 50% of adolescents who should be screened for depression are actually receiving that screen. And many teens with a positive depression screen do not receive high-quality follow-up care.
Certain screens that some health systems are now routinely conducting, such as those for social determinants of health and adverse childhood experiences, are not on the schedule at all. And even the strongest advocates of the schedule recognize it is not the be all, end all of pediatric primary care.
“For a visit to be successful, you have to address the family’s and child’s agenda first, before the periodicity schedule,” says Dr. Hagan. “Bright Futures is not meant to be more important that the conversation with the family. But there are certain things that can be done and should be done for the best preventive care.”
The Screening Struggle
In Dr. Kelleher’s telling, the pediatric primary care system does an excellent job of doing what it was conceptualized for in the 1940s — episodic visits for acute conditions that can be resolved fairly quickly. It should be no surprise that providers struggle in managing the ongoing developmental concerns of children, though. Those providers have been asked to do ever more without an overall system of support.
“We don’t have good tracking mechanisms, good follow-up systems, good data collection and flow across platforms, good relationships with specialists,” he says. “Effective screening is complicated, because the actual “screen” itself is such a small part. There are so many steps, from the patient actually showing up to be screened through the treatment of the condition.”
Many of the recommended early childhood physical health screenings do get performed routinely in primary care. Blood pressure, height and weight, vision and hearing. The tools for those are widely available and understood, families expect those kinds of screens, and they may be required for school and other activities.
Screening can be more difficult as a child ages, or when the screening goes beyond physical and into developmental and behavioral health, says Heather Maciejewski, manager, Clinical Center of Excellence, Partners For Kids. Among the quality improvement projects she leads are some directly tied to increasing screening rates in primary care.
Medicine is a team sport. There is a lot we still need to do to make sure that screenings are as efficient and effective as possible. We need to be smarter. Its all hard work, but if we do it, we can make a difference.
– Alex Kemper, MD, division chief of Primary Care Pediatrics at Nationwide Children’s Hospital
“Families may object to the screening because of the stigma associated with mental health issues,” she says. “As children age, they may refuse to do them. On the provider side, someone needs to be educated on how to administer a screen, on how to interpret the results, on how to talk to the families about the results if there is a positive screen. There’s staff turnover. Billing for screening can be confusing. And there is always time pressure in the visits.”
Ultimately, what to do after a screen is positive may be the biggest problem, even for basic physical issues. More than 50% of Dr. Neff’s patients are covered by Medicaid, and she says she has difficulty finding an optometrist to take referrals of those patients in her area. Nationwide Children’s, 80 miles away, has the closest dental clinic for her Medicaid patients.
“Then you’re talking about time off work, transportation, a family’s anxiety about traveling to a city that they’re unfamiliar with, extra visits for complex issues. . .” she says. “There is only so much I can do, but there is also only so much that I can ask them to do.”
Looking For Solutions
Despite the problems, screening can improve health.
“Just because we don’t do a perfect job isn’t a reason we shouldn’t do it,” Dr. Kemper says. “It’s really a call for us to do it better.”
Solutions are possible through improved systems and processes, according to nearly everyone involved — from the processes inside an individual pediatric practice to those at the health care system level. At the smallest scale, certain survey-based screenings can happen on a tablet in a waiting room, and the results can be scored before the actual appointment begins, alleviating some time pressure, says Dr. Kemper.
At Nationwide Children’s, the quality improvement projects spearheaded by Partners For Kids offer individualized solutions to the screening process, including setting up the steps for referral to specialized care if a screen is a positive, says Maciejewski. Part of the QI project involves training staff members on executing each part of the process. Having all of that in place before a screening even happens means there are fewer crises with a positive screen, she says.
Screening AND Surveillance
One of Dr. Kemper’s contributions to the Pediatrics supplement points out the differences between “screening” and “surveillance.” He suggests that focusing on surveillance, or the changes to a child’s health over time, reduces the pressure on screening, or a single threshold test during a single appointment. For example, if a child whose body mass index has been at the 50th percentile for their entire lives suddenly presents at the 70th percentile, that child still doesn’t screen as at risk for obesity. An observant provider will understand that surveillance is more important in that situation.
This, as it happens, is exactly Dr. Neff’s strategy in Jackson County.
“If I mention obesity, families get upset,” she says. “But if I notice a difference over time, I will say to the mom, ‘Has anything changed in your family in the last three months?’ and we work toward the issue that way.”
That’s what Dr. Kemper calls the “art of medicine.” It’s different from screening, but it’s in the service of the same goal. And there are other, larger-scale measures that can be considered upstream of screening, but that work hand-in-hand with screening to address health issues.
For instance, depression and anxiety are such population-level concerns in adolescence that screening one-by-one in a provider’s office should be considered only a part of well care. Prevention programs in schools reach a greater number of young people at once, and many themselves have a screening function. The Signs of Suicide® program trains school staff members to recognize and respond to young people at risk and includes many other prevention elements. The PAX Good Behavior Game® trains elementary school teachers in strategies to help children with self-regulation.
Nationwide Children’s administers both of the prevention programs in partnership with local districts, and both programs have good outcomes for children when delivered in schools. That, in the end, is the point of screening and preventive care, no matter how it is carried out.
“Medicine is a team sport,” Dr. Kemper says. “There is a lot we still need to do to make sure that screenings are as efficient and effective as possible. We need to be smarter. It’s all hard work, but if we do it, we can make a difference.”
This article appears in the 2021 Fall/Winter print issue. Download the full issue.
- Committee on Practice and Ambulatory Medicine, Bright Futures Periodicity Schedule Workgroup. 2021 recommendations for preventive pediatric health care. Pediatrics. 2021 Mar;147(3): e2020049776
- Gardner W, Bevans K, Kelleher KJ. The potential for improving the population health effectiveness of screening: A simulation study. Pediatrics. 2021 Jul;148(Suppl 1): s3-s10.
- Kemper AR, Letostak T, Grossman DC. Incorporating longitudinal surveillance into the delivery of pediatric screening services. Pediatrics. 2021 Jul;148(Suppl 1): s33-s36
- Wilson JM, Jungner YG. Principles and practice of screening for disease. Geneva: World Health Organization; 1968.
Image credits: American Academy of Pediatrics; Nationwide Children’s (Heather Maciejewski, Alex Kemper, MD)
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