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Matthews S, Qureshi N, Levin JS, Eberhart NK, Breslau J, McBain RK. Financial Interventions to Improve Screening in Primary Care: A Systematic Review. Am J Prev Med 2024; 67:134-146. [PMID: 38484900 DOI: 10.1016/j.amepre.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 06/23/2024]
Abstract
INTRODUCTION Although health screenings offer timely detection of health conditions and enable early intervention, adoption is often poor. How might financial interventions create the necessary incentives and resources to improve screening in primary care settings? This systematic review aimed to answer this question. METHODS Peer-reviewed studies published between 2000 and 2023 were identified and categorized by the level of intervention (practice or individual) and type of intervention, specifically alternative payment models (APMs), fee-for-service (FFS), capitation, and capital investments. Outcomes included frequency of screening, performance/quality of care (e.g., patient satisfaction, health outcomes), and workflow changes (e.g., visit length, staffing). RESULTS Of 51 included studies, a majority focused on practice-level interventions (n=32), used APMs (n=41) that involved payments for achieving key performance indicators (KPIs; n=31) and were of low or very low strength of evidence based on GRADE criteria (n=42). Studies often included screenings for cancer (n=32), diabetes care (n=18), and behavioral health (n=15). KPI payments to both practices and individual providers corresponded with increased screening rates, whereas capitation and provider-level FFS models yielded mixed results. A large majority of studies assessed changes in screening rates (n=48) with less focus on quality of care (n=11) or workflow changes (n=4). DISCUSSION Financial mechanisms can enhance screening rates with evidence strongest for KPI payments to both practices and individual providers. Future research should explore the relationship between financial interventions and quality of care, in terms of both clinical processes and patient outcomes, as well as the role of these interventions in shaping care delivery.
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Affiliation(s)
| | | | | | | | | | - Ryan K McBain
- Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts; RAND Corporation, Arlington, Virginia
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Arrojo MJ, Bromberg J, Walter HJ, Vernacchio L. Pediatric Primary-Care Integrated Behavioral Health: A Framework for Reducing Inequities in Behavioral Health Care and Outcomes for Children. Pediatr Clin North Am 2023; 70:775-789. [PMID: 37422314 DOI: 10.1016/j.pcl.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
Nearly half of US children and adolescents will suffer a behavioral health (BH) disorder, with substantially higher rates among more disadvantaged children such as racial/ethnic minorities, LGBTQ + youth, and poor children. The current specialty pediatric BH workforce is inadequate to meet the need and the uneven distribution of specialists as well as other barriers to care, such as insurance coverage and systemic racism/bias, further exacerbate disparities in BH care and outcomes. Integrating BH care into the pediatric primary care medical home has the potential to expand access to BH care and reduce the disparities inherent in the current system.
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Affiliation(s)
- Maria J Arrojo
- Pediatric Physicians' Organization at Children's, 112 Worcester Street, Suite 300, Wellesley, MA 02481, USA; Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Jonas Bromberg
- Pediatric Physicians' Organization at Children's, 112 Worcester Street, Suite 300, Wellesley, MA 02481, USA; Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Heather J Walter
- Pediatric Physicians' Organization at Children's, 112 Worcester Street, Suite 300, Wellesley, MA 02481, USA; Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Louis Vernacchio
- Pediatric Physicians' Organization at Children's, 112 Worcester Street, Suite 300, Wellesley, MA 02481, USA; Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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Screening Infants Through Adolescents for Social/Emotional/Behavioral Problems in a Pediatric Network. Acad Pediatr 2022:S1876-2859(22)00540-X. [PMID: 36280038 DOI: 10.1016/j.acap.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/14/2022] [Accepted: 10/15/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess changes in screening completion in a diverse, 7-clinic network after making annual screening for social/emotional/behavioral (SEB) problems the standard of care for all infant through late adolescent-aged patients and rolling out a fully automated screening system tied to the electronic medical record and patient portal. METHODS In 2017, the Massachusetts General Hospital made SEB screening using the age-appropriate version of the Pediatric Symptom Checklist the standard of care in its pediatric clinics for all patients aged 2.0 months to 17.9 years. Billing records identified all well-child visits between January 1, 2016 and December 31, 2019. For each visit, claims were searched for billing for an SEB screen and the electronic data warehouse was queried for an electronically administered screen. A random sample of charts was reviewed for other evidence of screening. Chi-square analyses and generalized estimating equations assessed differences in screening over time and across demographic groups. RESULTS Screening completion (billing and/or electronic) significantly increased from 2016 (37.2%) through 2019 (2017 [46.2%] vs 2018 [66.8%] vs 2019 [70.9%]; χ2 (3) =112652.33, P < .001), with an even higher prevalence found after chart reviews. Most clinics achieved screening levels above 90% by the end of 2019. Differences among demographic groups were small and dependent on whether data were aggregated at the clinic or system level. CONCLUSIONS Following adoption of a best-practice policy and implementation of an electronic system, SEB screening increased in all age groups and clinics. Findings demonstrate that the AAP recommendation for routine psychosocial assessment is feasible and sustainable.
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Sheldrick RC, Bair-Merritt MH, Durham MP, Rosenberg J, Tamene M, Bonacci C, Daftary G, Tang MH, Sengupta N, Morris A, Feinberg E. Integrating Pediatric Universal Behavioral Health Care at Federally Qualified Health Centers. Pediatrics 2022; 149:185679. [PMID: 35347338 DOI: 10.1542/peds.2021-051822] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Research supports integrated pediatric behavioral health (BH), but evidence gaps remain in ensuring equitable care for children of all ages. In response, an interdisciplinary team codeveloped a stepped care model that expands BH services at 3 federally qualified health centers (FQHCs). METHODS FQHCs reported monthly electronic medical record data regarding detection of BH issues, receipt of services, and psychotropic medications. Study staff reviewed charts of children with attention-deficit/hyperactivity disorder (ADHD) before and after implementation. RESULTS Across 47 437 well-child visits, >80% included a complete BH screen, significantly higher than the state's long-term average (67.5%; P < .001). Primary care providers identified >30% of children as having BH issues. Of these, 11.2% of children <5 years, 53.8% of 5-12 years, and 74.6% >12 years were referred for care. Children seen by BH staff on the day of referral (ie, "warm hand-off") were more likely to complete an additional BH visit than children seen later (hazard ratio = 1.37; P < .0001). There was no change in the proportion of children prescribed psychotropic medications, but polypharmacy declined (from 9.5% to 5.7%; P < .001). After implementation, diagnostic rates for ADHD more than doubled compared with baseline, follow-up with a clinician within 30 days of diagnosis increased (62.9% before vs 78.3% after; P = .03) and prescriptions for psychotropic medication decreased (61.4% before vs 43.9% after; P = .03). CONCLUSIONS Adding to a growing literature, results demonstrate that integrated BH care can improve services for children of all ages in FQHCs that predominantly serve marginalized populations.
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Affiliation(s)
| | | | - Michelle P Durham
- Psychiatry, Boston University School of Medicine, Boston, Massachusetts.,Psychiatry, Boston Medical Center, Boston, Massachusetts
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Gardner W, Bevans K, Kelleher KJ. The Potential for Improving the Population Health Effectiveness of Screening: A Simulation Study. Pediatrics 2021; 148:s3-s10. [PMID: 34210841 DOI: 10.1542/peds.2021-050693c] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Screening interventions in pediatric primary care often have limited effects on patients' health. Using simulation, we examined what conditions must hold for screening to improve population health outcomes, using screening for depression in adolescence as an example. METHODS Through simulation, we varied parameters describing the working recognition and treatment of depression in primary care. The outcome measure was the effect of universal screening on adolescent population mental health, expressed as a percentage of the maximum possible effect. Through simulations, we randomly selected parameter values from the ranges of possible values identified from studies of care delivery in real-world pediatric settings. RESULTS We examined the comparative effectiveness of universal screening over assessment as usual in 10 000 simulations. Screening achieved a median of 4.2% of the possible improvement in population mental health (average: 4.8%). Screening had more impact on population health with a higher sensitivity of the screen, lower false-positive rate, higher percentage screened, and higher probability of treatment, given the recognition of depression. However, even at the best levels of each of these parameters, screening usually achieved <10% of the possible effect. CONCLUSIONS The many points at which the mental health care delivery process breaks down limit the population health effects of universal screening in primary care. Screening should be evaluated in the context of a realistic model of health care system functioning. We need to identify health care system structures and processes that strengthen the population effectiveness of screening or consider alternate solutions outside of primary care.
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Affiliation(s)
- William Gardner
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario; .,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Katherine Bevans
- Health and Rehabilitation Sciences, College of Public Health, Temple University, Philadelphia, Pennsylvania
| | - Kelly J Kelleher
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio.,Nationwide Children's Hospital Research Institute, Columbus, Ohio
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Murphy JM, Stepanian S, Riobueno-Naylor A, Holcomb JM, Haile H, Dutta A, Giuliano CP, Bernstein SC, Joseph B, Shui AM, Jellinek MS. Implementation of an Electronic Approach to Psychosocial Screening in a Network of Pediatric Practices. Acad Pediatr 2021; 21:702-709. [PMID: 33285307 DOI: 10.1016/j.acap.2020.11.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE A network of 18 pediatric practice locations serving predominantly commercially insured patients implemented the electronic administration of the Pediatric Symptom Checklist-17 parent-report (PSC-17P) for all 5.50- to 17.99-year-old children seen for well child visits (WCVs) and wrote up the results as a quality improvement project. The current study investigated this screening over 2 years to assess its implementation and risk rates over time. METHODS Parents completed the PSC-17P electronically before the visit and the scored data were immediately available in the patient's chart. Using billing and screening data, the study tracked rates of overall and positive screening during the first-year baseline (4 months) and full implementation phases of the project in the first (8 months) and second (12 months) year. RESULTS A total of 35,237 patients completed a WCV in the first year. There was a significant improvement in PSC-17P screening rates from the first-year baseline (26.3%) to full implementation (89.3%; P < .001) phases. In the second year, a total of 40,969 patients completed a WCV and 77.9% (n = 31,901) were screened, including 18,024 patients with screens in both years. PSC-17P screening rates varied significantly across the 18 locations and rates of PSC-17P risk differed significantly by practice, insurance type, sex, and age. CONCLUSIONS The current study demonstrated the feasibility of routine psychosocial screening over 2 years using the electronically administered PSC-17P in a network of pediatric practices. This study also corroborated past reports that PSC-17 risk rates differed significantly by insurance type (Medicaid vs commercial), sex, and age group.
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Affiliation(s)
- J Michael Murphy
- Department of Psychiatry (JM Murphy, A Riobueno-Naylor, JM Holcomb, A Dutta, MS Jellinek), Massachusetts General Hospital, Boston, Mass; Department of Psychiatry (JM Murphy, MS Jellinek), Harvard Medical School, Boston, Mass.
| | - Salpi Stepanian
- Department of Clinical and Quality Programs (S Stepanian, CP Giuliano, SC Bernstein), Affiliated Pediatric Practices, Dedham, Mass
| | - Alexa Riobueno-Naylor
- Department of Psychiatry (JM Murphy, A Riobueno-Naylor, JM Holcomb, A Dutta, MS Jellinek), Massachusetts General Hospital, Boston, Mass
| | - Juliana M Holcomb
- Department of Psychiatry (JM Murphy, A Riobueno-Naylor, JM Holcomb, A Dutta, MS Jellinek), Massachusetts General Hospital, Boston, Mass
| | - Haregnesh Haile
- Department of Psychology (H Haile), The Catholic University of America, Washington, DC
| | - Anamika Dutta
- Department of Psychiatry (JM Murphy, A Riobueno-Naylor, JM Holcomb, A Dutta, MS Jellinek), Massachusetts General Hospital, Boston, Mass
| | - Christopher P Giuliano
- Department of Clinical and Quality Programs (S Stepanian, CP Giuliano, SC Bernstein), Affiliated Pediatric Practices, Dedham, Mass
| | - Shelly C Bernstein
- Department of Clinical and Quality Programs (S Stepanian, CP Giuliano, SC Bernstein), Affiliated Pediatric Practices, Dedham, Mass; Department of Pediatrics (SC Bernstein, MS Jellinek), Harvard Medical School, Boston, Mass
| | | | - Amy M Shui
- Biostatistics Center (AM Shui), Massachusetts General Hospital, Boston, Mass
| | - Michael S Jellinek
- Department of Psychiatry (JM Murphy, A Riobueno-Naylor, JM Holcomb, A Dutta, MS Jellinek), Massachusetts General Hospital, Boston, Mass; Department of Psychiatry (JM Murphy, MS Jellinek), Harvard Medical School, Boston, Mass; Department of Pediatrics (SC Bernstein, MS Jellinek), Harvard Medical School, Boston, Mass
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Arauz-Boudreau A, Riobueno-Naylor A, Haile H, Holcomb JM, Lucke CM, Joseph B, Jellinek MS, Murphy JM. How an Electronic Medical Record System Facilitates and Demonstrates Effective Psychosocial Screening in Pediatric Primary Care. Clin Pediatr (Phila) 2020; 59:154-162. [PMID: 31808350 DOI: 10.1177/0009922819892038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Using questionnaires, administrative claims, and chart review data, the current study explored the impact of using an electronic medical record system to administer, score, and store the Pediatric Symptom Checklist (PSC-17) during annual pediatric well-child visits. Within a sample of 1773 Medicaid-insured outpatients, the electronic system demonstrated that 90.5% of cases completed a PSC-17 screen electronically, billing codes indicating a screen was administered agreed with the existence of a questionnaire in the chart in 98.8% of cases, the classification of risk based on PSC-17 scores agreed with the classification of risk based on the Current Procedural Terminology code modifiers in 72.9% of cases, and 90.0% of clinicians' progress notes mentioned PSC-17 score in treatment planning. Using an electronic approach to psychosocial screening in pediatrics facilitated the use of screening information gathered during the clinical visit and allowed for enhanced tracking of outcomes and quality monitoring.
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Affiliation(s)
- Alexy Arauz-Boudreau
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | - Michael S Jellinek
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - J Michael Murphy
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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