Interventions to Improve Screening and Follow-Up in Primary Care: A Systematic Review of the Evidence

Abstract

Background The American Academy of Pediatrics and other organizations recommend several screening tests as part of preventive care. The proportion of children who are appropriately screened and who receive follow-up care is low. Objective To conduct a systematic review of the evidence for practice-based interventions to increase the proportion of patients receiving recommended screening and follow-up services in pediatric primary care. Data source Medline database of journal citations. Study eligibility criteria, participants, and interventions We developed a strategy to search Medline to identify relevant articles. We selected search terms to capture categories of conditions (e.g., developmental disabilities, obesity), screening tests, specific interventions (e.g., quality improvement initiatives, electronic records enhancements), and primary care. We searched references of selected articles and reviewed articles suggested by experts. We included all studies with a distinct, primary care-based intervention and post-intervention screening data, and studies that focused on children and young adults (≤21 years of age). We excluded studies of newborn screening. Study appraisal and synthesis methods Abstracts were screened by 2 reviewers and articles with relevant abstracts received full text review and evaluated for inclusion critieria. A structured tool was used to abstract data from selected articles. Because of heterogeneous interventions and outcomes, we did not attempt a meta-analysis. Results From 2547 returned titles and abstracts, 23 articles were reviewed. Nine were pre-post comparisons, 5 were randomized trials, 3 were post-intervention comparisons with a control group, 3 were post-intervention cross-sectional analyses only, and 3 reported time series data. Of 14 articles with pre-intervention or control group data and significance testing, 12 reported increases in the proportion of patients appropriately screened. Interventions were heterogeneous and often multifaceted, and several types of interventions, such as provider/staff training, electronic medical record templates/prompts, and learning collaboratives, appeared effective in improving screening quality. Few articles described interventions to track screening results or referral completion for those with abnormal tests. Data were often limited by single-site, non-randomized design. Conclusions Several feasible, practice- and provider-level interventions appear to increase the quality of screening in pediatric primary care. Evidence for interventions to improve follow-up of screening tests is scant. Future research should focus on which specific interventions are most effective, whether effects are sustained over time, and what interventions improve follow-up of abnormal screening tests.

Practice-Tailored Facilitation to Improve Pediatric Preventive Care Delivery: A Randomized Trial

“…Several previous studies evaluated practice coaching to improve pediatric preventive service delivery in community practices, including rapid-cycle feedback, 31,[58][59][60][61][62][63][64][65] academic detailing, and learning collaboratives; some targeted single services and used a higher facilitator-to-practice ratio. 31,66,67 Previous studies have not described practice-specific characteristics associated with improvement.…”

Screenings during Well-Child Visits in Primary Care: A Quality Improvement Study

“…As per Van Cleave et al's 22 systematic review of interventions to improve the quality of screening after an intervention, a modest improvement is typical. The current research illustrates similar findings despite the differences across and within studies of the systematic review.…”

“…21 Previous investigators have attempted to improve the delivery of well-child screenings. Van Cleave et al 22 reviewed 23 articles to synthesize evidence for interventions to improve such screening in primary care settings. Of the 23 articles, 5 were based on randomized controlled trials and 18 were based on observational studies.…”

“…In the systematic review, screening tests, such as developmental delay, mental health conditions, vision problems, hearing problems, lead poisoning and anemia, were selected based on recommendations from AAP/ Bright Futures, the USPSTF, and the Centers for Disease Control and Prevention. 22 Given the compelling rationale for conducting a battery of routine well-child screenings in the primary care setting, we sought to evaluate the efficacy of baseline screening delivery in our practice, qualitatively develop an intervention and use it to measure the impact, and to conduct a postintervention qualitative assessment to identify areas potential for further improvement.…”

Practice-Tailored Facilitation to Improve Pediatric Preventive Care Delivery: A Randomized Trial

“…31,66,67 Previous studies have not described practice-specific characteristics associated with improvement. 34,61,65 Our PTFI program led to large improvements in all 3 services: obesity detection/ counseling, lead screening, and fluoride application. Most improvements were broad-based with no difference in improvement across practices with different characteristics.…”