Effect of a Computer-Based Decision Support Intervention on Autism Spectrum Disorder Screening in Pediatric Primary Care Clinics : A Cluster Randomized Clinical Trial

Key Points

Question

Can computer automation coupled with decision support increase timely screening for autism spectrum disorders in primary care practice?

Findings

This cluster randomized clinical trial found that computer-based screening and decision support embedded into the routine workflow in primary care increased rates of screening from 0% to 100%, but physicians responded to approximately half of positive screening results.

Meaning

Automating the screening process can ensure that screening takes place, but follow-through of the results is vulnerable to human error.

Abstract

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

Abstract

This randomized clinical trial examines whether computer-automated screening and clinical decision support can improve autism spectrum disorder screening rates in a pediatric primary care practice.