Use of a Digital Modified Checklist for Autism in Toddlers - Revised with Follow-up to Improve Quality of Screening for Autism

Abstract

Objectives: To assess changes in quality of care for children at risk for autism spectrum disorders (ASD) due to process improvement and implementation of a digital screening form.

Study design: The process of screening for ASD was studied in an academic primary care pediatrics clinic before and after implementation of a digital version of the Modified Checklist for Autism in Toddlers - Revised with Follow-up with automated risk assessment. Quality metrics included accuracy of documentation of screening results and appropriate action for positive screens (secondary screening or referral). Participating physicians completed pre- and postintervention surveys to measure changes in attitudes toward feasibility and value of screening for ASD. Evidence of change was evaluated with statistical process control charts and χ² tests.

Results: Accurate documentation in the electronic health record of screening results increased from 54% to 92% (38% increase, 95% CI 14%-64%) and appropriate action for children screening positive increased from 25% to 85% (60% increase, 95% CI 35%-85%). A total of 90% of participating physicians agreed that the transition to a digital screening form improved their clinical assessment of autism risk.

Conclusions: Implementation of a tablet-based digital version of the Modified Checklist for Autism in Toddlers - Revised with Follow-up led to improved quality of care for children at risk for ASD and increased acceptability of screening for ASD. Continued efforts towards improving the process of screening for ASD could facilitate rapid, early diagnosis of ASD and advance the accuracy of studies of the impact of screening.

Keywords: M-CHAT; early detection.

Figure 1. Flow chart of patients screened for Autism during baseline and intervention periods

Baseline (grey boxes) and intervention (white boxes) measures of screening with electronic and paper M-CHAT-R, with % difference and 95% confidence interval of difference (blue boxes). a -newly-identified positives refers to children who do not already have a diagnosis of ASD or other developmental delay and are not already receiving treatment. b –appropriate action refers to use of the follow up questions or immediate referral for evaluation. **p<0.005, ***p<0.001

Figure 2. Control charts of monthly changes in process measures

Statistically significant improvement (circle markers) starting in the second month of intervention for (A) proportion of positives documented in EMR and (B) proportion of positives with appropriate action by the physician. Vertical, dashed line separates baseline and intervention periods. Dashed horizontal lines show control limits (1, 2, and 3 standard deviations from baseline mean).