Barriers to referral and evaluation and corresponding navigation services for toddlers screening positive for autism spectrum disorder

INTRODUCTION

Children from disadvantaged populations receive referrals, diagnoses, and services for autism spectrum disorder (ASD) late or not at all. We describe barriers to referral for and receipt of evaluation for ASD among young children from disadvantaged families and activities by autism family navigators (AFNs) to address these barriers.

METHOD

Trained AFNs offered navigation to families of children aged 16-30 months with positive ASD screens from community health center clinics in 2015-2018. AFNs interviewed families to identify perceived barriers to care and documented system barriers and navigation activities. We coded, categorized, and described barriers and AFN activities. Case studies illustrate barriers and navigation activities.

RESULTS

Of 22 participating mothers, 82% were Latinx and 64% were native Spanish-speaking; 71% had household incomes <$30,000/year and 57% had no high school diploma. Half of the families experienced five or more barriers to ASD evaluation, most commonly pragmatic barriers. Information barriers/needs were 5 times more common among Spanish-speaking than English-speaking mothers. One-fifth of families identified negative experiences or expectations of care. System barriers included incomplete screening tests, inadequate referrals, and waiting lists. AFNs implemented navigation activities, most frequently categorized as care coordination (95%), education (68%), social/emotional support (36%), family advocacy (27%), and self-advocacy coaching (23%). AFNs also trained providers and staff to improve screening and referral implementation.

DISCUSSION

In this largely Latinx sample, families experienced numerous barriers to obtaining ASD evaluations for their screen-positive children, likely reflecting the complexity of negotiating both healthcare and educational systems. Trained AFNs can assist parents to overcome barriers to timely diagnosis. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Examining the Implementation of Health-Related Social Need (HRSN) Screenings at a Pediatric Community Health Center

INTRODUCTION

Social determinants of health (SDoH) influence health outcomes and screening for health-related social needs (HRSN) is a recommended pediatric practice. In 2018, Denver Health and Hospitals (DH) implemented the Accountable Health Communities (AHC) model under the Centers for Medicare and Medicaid Services (CMS) and began using the AHC HRSN screening tool during selected well child visits (WCVs) at a DH Federally Qualified Health Center (FQHC). The current evaluation aimed to examine the program implementation and identify key lessons learned to inform the expansion of HRSN screening and referral to other populations and health systems.

METHODS

Patients who completed a WCV between June 1, 2020 and December 31, 2021 (N = 13 750) were evaluated. Frequencies and proportions were used to describe patient characteristics of those that had a WCV, were screened, and received resource information. Multivariable logistic regression models with odds ratios (OR) and 95% confidence intervals (CI) were used to determine the association between patient characteristics and completing HRSN screening and provision of resource information.

RESULTS

The screening tool was completed by 80% (n = 11 004) of caregivers bringing children to a WCV at the DH Westside Clinic, with over one-third (34.8%; n = 3830) reporting >1 social need. Food insecurity was the most common concern (22.3%; n = 2458). Non-English, non-Spanish (NENS) speakers were less likely to be screened (OR 0.43, 95% CI 0.33, 0.57) and less likely to report a social need (OR 0.59, 95% CI 0.42, 0.82) than speakers of English, after adjusting for age, race/ethnicity, and health insurance.

CONCLUSIONS

A high rate of screening indicates feasibility of administering HRSN screenings for pediatric patients in a busy FQHC. More than a third of patients reported one or more social needs, underscoring the importance to identity these needs and the opportunity to offer personalized resources. Comparatively lower rates of screening and potential underreporting among NENS may be indicative of the availability and acceptability of current translation procedures as well as how the tool translates linguistically and culturally. Our experience highlights the need to partner with community organizations and involve patients and families to ensure SDoH screening and care navigation is part of culturally-appropriate patient-centered care.

Closing the Equity Gap: An Intervention to Improve Chlamydia and Gonorrhea Testing for Adolescents and Young Adults in Primary Care

BACKGROUND

Chlamydia trachomatis and Neisseria gonorrhea are the most reported sexually transmitted infections in the United States. Testing rates remain suboptimal and may be subject to implicit bias. We evaluated the effectiveness of an opt-out chlamydia and gonorrhea testing program for adolescents and young adults in improving testing rates and promoting equity.

METHODS

An opt-out testing program that standardized testing to once annually for 14 to 24-year-old patients was implemented across 28 federally qualified health centers spanning 4 specialties. A quasi-experimental design using interrupted time series analyses evaluated testing and infection rates between baseline, intervention, and pandemic-associated test shortage periods. Reduction in testing inequities based on sex, race, ethnicity, insurance, and language preference were also examined.

RESULTS

A total of 57 452 encounters during the baseline, 17 320 during the intervention, and 26 993 during the test supply shortage periods were included. Testing increased from 66.8% to 81.0% (14.2% absolute increase) between baseline and intervention periods. Pediatric clinics demonstrated the largest improvement compared to other settings (absolute increase 30.9%). We found significant reductions in testing inequities for language preference (P < .001), and un-insured and public insured individuals (P < .001). More cases of chlamydia and gonorrhea were detected in the intervention period (chlamydia-29.7; gonorrhea-7.4 per 1000 patients) than in the baseline period (chlamydia-20.7; gonorrhea-4.4 per 1000 patients; P < .001).

CONCLUSIONS

An opt-out approach increased testing, reduced inequities between some groups and detected more infections than a risk-based approach. Opt-out testing should be considered as an approach to increase detection of chlamydia and gonorrhea and promote equity.

An Intervention to Improve Chlamydia and Gonorrhea Testing Among Adolescents in Primary Care

BACKGROUND AND OBJECTIVES

Rates of chlamydia and gonorrhea among adolescents continue to rise. We aimed to evaluate if a universal testing program for chlamydia and gonorrhea improved testing rates in an urban general pediatric clinic and an urban family medicine clinic within a system of federally qualified health care centers and evaluated the feasibility, cost, and logistic challenges of expanding implementation across 28 primary care clinics within a federally qualified health care centers system.

METHODS

A universal testing quality improvement program for male and female patient 14 to 18 years old was implemented in a general pediatrics and family medicine clinic in Denver, Colorado. The intervention was evaluated by using a controlled pre-post quasi-experimental design. The difference in testing rates due to the intervention was assessed by using a difference-in-differences regression model weighted with the inverse probability of treatment.

RESULTS

In total, 15 541 pediatric encounters and 5420 family medicine encounters were included in the analyses. In pediatrics, the unadjusted testing rates increased from 32.0% to 66.7% in the intervention group and from 20.9% to 28.9% in the comparison group. For family medicine, the rates increased from 38.5% to 49.9% in the intervention group and decreased from 26.3% to 24.8% in the comparison group. The intervention resulted in an adjusted increase in screening rates of 25.2% (P < .01) in pediatrics and 11.8% (P < .01) in family medicine. The intervention was well received and cost neutral to the clinic.

CONCLUSIONS

Universal testing for chlamydia and gonorrhea in primary care pediatrics and family medicine is a feasible approach to improving testing rates .

Gonorrhea and Chlamydia Rates Among 12- to 24-Year-Old Patients in an Urban Health System

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infection rates continue to rise. Screening guidelines have largely focused on sexually active female individuals and men who have sex with men populations. Health care system testing and infection rates, particularly among heterosexual male individuals, are poorly understood. Our aim was to evaluate CT and GC testing and prevalence among 12- to 24-year-old patients in an urban federally qualified health center system.

METHODS

This retrospective study analyzed electronic health record data from 2017 to 2019 in a large system of federally qualified health centers in Denver, CO. Abstracted data included demographics, sexual activity, sexual orientation, and laboratory results. χ2 Tests were used to evaluate differences between groups.

RESULTS

Of the 44,021 patients included, 37.6% were tested, 15.0% were positive for CT, and 3.4% were positive for GC. Heterosexual male patients had a testing rate of 22.8% and positivity rates of CT and GC at 13.1% and 3.0%, respectively. Among tested patients documented as not sexually active, 7.5% were positive for CT. Multiple or reinfections were detected in 29% of patients.

CONCLUSIONS

This study shows low testing rates and high rates of CT and GC infections among all patients, including heterosexual male patients and those documented as not sexually active. Improved screening of these populations in the primary care setting may be key to combating the sexually transmitted disease epidemic.

418. Testing and Positivity Rates for Gonorrhea and Chlamydia in a Large Federally Qualified Health Center System

Background

Gonorrhea (GC) and Chlamydia (CT) are the most reported sexually transmitted infections in the United States. Little is known about testing and positivity rates for GC/CT in clinical practice, particularly for male patients. In this study, we analyzed rates of GC/CT testing and positivity among 11–24 years old patients presenting to a system of federally qualified health centers (FQHC).

Methods

This retrospective data review was conducted at Denver Health (DH) in Denver, CO. Data were abstracted for 11–24 years old who were seen at least once at a DH FQHC in 2018. Abstracted data included patient age, gender, clinic location, and testing for GC/CT. The percentage of patients tested ≥1 time within the preceding year and the percentage of tested patients that were positive for GC and/or CT ≥1 time were calculated along with Wald 95% confidence intervals.

Results

In total, 34,416 unique patients were included. GC/CT testing was completed for 7.3% (95% CI: 6.8%, 7.6%) of 11–15 years old, 30.6% (95% CI: 29.5%, 31.6%) of 16–18 years old, and 45.6% (95% CI: 44.8%, 46.4%) of 19–24 years old. Rates of testing varied by gender and age and were lowest among males and younger patients (Figure 1). Of patients tested, 11.4% (95% CI: 10.7%, 12.1%) of females and 9.1% (95% CI: 7.8%, 10.4%) of males were positive for CT and 1.7% (95% CI: 1.4%, 2.0%) of females and 2.3% (95% CI: 1.6%, 2.9%) of males were positive for GC (Figure 2). Though less likely to be tested than older patients, females 11–15 years old had the highest rates of GC (2.1%; 95% CI: 1.2%, 3.0%) and the second highest rate of CT (13.5%; 95% CI: 11.3%, 15.6%) among females tested.

Conclusion

Despite efforts to improve GC/CT screening, less than 50% of 11–24 years old patients were tested within the prior year. Rates of GC/CT were higher than previously reported, particularly for females less than 16 years old. Male patients were less likely to be tested; however, the males who were tested had higher GC positivity rates and only slightly lower rates of CT than females who were tested. Future studies evaluating the effectiveness of interventions to reduce GC/CT among 11–24 years old are critically needed.

Disclosures

All authors: No reported disclosures.