Table 2.

Interventions to improve screening and follow-up of abnormal screening tests in pediatric primary care, by type of study design

Author, year, design	Condition(s) being screened and screening test(s)	Pre-Intervention or control group screening (%of patients screened, unless otherwise specified)	Post-Intervention or experimental group screening (% of patients screened, unless otherwise specified)	Significance testing (p-value unless otherwise specified)	Nature of the intervention, setting/population, and other comments about the study
Randomized Controlled Trials
1. Margolis PA, et al. (2004) RCT20	Lead poisoning, anemia, and tuberculosis: Serum lead level: Intervention Control	23% 18%	68% 30%	<0.05	Intervention: Process improvement methods (aka “knowledge translation”) to improve office systems around preventive care services. Formation of practice-based improvement teams Ongoing academic detailing by project staff Plan-do-study-act cycles with goal setting, workflow mapping, audit/feedback. Setting/population: 44 practices in North Carolina were randomized to intervention vs. usual care; n=~660 each for post-intervention control and experimental groups; children aged 24–30 months. Other comments: Data were collected pre- and post-intervention for both control and experimental group practices. Tuberculosis screening was PPD, Mantoux test, or risk assessment
	Hematocrit: Intervention Control	65% 64%	79% 71%	<0.05
	Tuberculosis screening: Intervention Control	34% 30%	54% 32%	<0.05
2. Minkovitz CS, et al. (2003) RCT35	Developmental problems: Parent-reported developmental assessment	41–43%	82–84%	<0.001	Intervention: Healthy Steps (HS) program a. Co-located developmental specialists to enhance well-child visits; also conducted home visits, provided telephone information line for parents about development, written materials, parent groups, linkages to community resources Setting/population: 15 practices randomized in 14 states; experimental n=2021 patients, control n=1716 patients; post-intervention data were collected for children aged 30–33 months. Other comments: Parents reported any developmental screening questions (not specifically whether a formal tool was used)
3. Scholes D, et al. (2006) RCT27	Chlamydia infection: Urine Chlamydia screening	Practice-level intervention: 37.5%	39.6%	0.31	Intervention: Practice and patient-level interventions Practice-level intervention—Use of peer opinion leader teams; 1 day training session around implementing screening guidelines; quarterly feedback reports on screening quality Patient level intervention--EMR point-of-care reminder to screen sexually-active adolescent females Setting/population: 23 practices in Washington state; experimental n=3511 patients, control n=3649 patients; females aged 14–20 years.
		EMR reminder: 40.8%	42.6%	0.27
4. Shafer MA, et al. (2002) RCT23	Chlamydia infection: Urine Chlamydia screening	21%	65%	<0.001	Intervention: Quality improvement initiative within managed care network Practices formed improvement teams; monthly meetings to strategize about solutions to self-identified barriers to screening, using Plan-Do-Study-Act cycles; performance monitoring Intervention targeted preventive care visits Setting/population: 10 pediatric practices in California; experimental n=1017 patients, control n=1194 patients; sexually active adolescent females.
5. Tebb KP, et al. (2009) RCT29	Chlamydia infection: Urine Chlamydia screening Intervention Control	26% 32%	42% 30%	<0.001	Intervention: Quality improvement initiative within managed care network Practices formed improvement teams; monthly meetings with focus on workflow, performance monitoring using Plan-Do-Study-Act cycles Intervention targeted urgent care visits Setting/population: 10 pediatric practices in California; n was not reported; sexually active adolescent females Other comments: Data were collected pre- and post-intervention for both control and experimental group practices.
Pre-post intervention design
6. Adams WG et al. (2003) Pre-post37	Developmental problems, anemia, lead poisoning, hearing and vision problems: Language development	65.1%	70.0%	Relative risk (95% confidence interval): 1.07 (0.97–1.09)	Intervention: EMR template with prompts to improve preventive care services Prompts included were age-specific milestones regarding development in social, fine/gross motor, and language skills, with checkboxes and normal ranges. Other prompts were for anticipatory guidance and screening for psychosocial problems. Setting/population: One practice in Massachusetts with >28,000 visits/year; pre-intervention n=235 patients; post-intervention n=986 patients; children aged 0–5 years Other comments: Pre-intervention group had paper charts with well-child visit templates; sample for specific tests varied because some tests are recommended only for a subset based on age.
	Behavior/social development	26.4%	65.7%	1.16 (1.04–1.28)
	Motor development	63.8%	73.9%	2.49 (2.00–3.10)
	Hematocrit	82.5%	85.3%	1.03 (0.91–1.17)
	Serum lead level	66.7%	79.1%	1.19 (0.99–1.43)
	Vision	42.9%	50.0%	1.17 (0.80–1.70)
	Hearing	33.3%	48.3%	1.45 (0.92–2.28)
7. Applegate H, et al. (2003) Pre-post33	Behavior, developmental and emotional problems: Discussion about behavior, developmental or emotional problems (# items discussed per visit)	1.6 items	10.4 items per visit after Stage 1; 9.9 items per visit after Stage 2		Intervention: Provider education and support tools to implement Pediatric Symptom Checklist (PSC); intervention was 2 stages Stage 1: Provider training session about screening tool, importance of screening, screener placed on medical chart Stage 2: Implementation of provider and patient handouts that followed the structure of the PSC and were designed to address specific subgroups of symptoms. Setting/population: One academic pediatric practice; pre-intervention n=16 patients; post-intervention n=38 patients; children aged 6–16 years. Other comments: No significance testing reported
	Intervention for behavior and emotional problems (# of interventions per visit)	0 interventions	0.125 interventions per visit after Stage 1; 1.9 interventions per visit after Stage 2
8. Block B, et al. (1996) Pre-post40	Follow up of elevated lead levels: Follow up plan in chart	32%	100%		Intervention: Nurse-led protocol to follow up abnormally elevated lead levels-- Case management performed by a nurse Nurse-initiated physician education on specific cases Electronic tracking of patients within the practice Joint tracking of patients with public health department Setting/population: One academic family medicine practice in Pennsylvania; pre intervention n=22 patients with abnormal lead levels, post intervention n=99 patients with abnormal lead levels Other comments: No significance testing reported
	Follow up serum lead level done	9%	65%
	Parent education about reducing exposure, if persistently high levels	Not measured	28%
9. Bordley WC, et al. (2001) Pre-post22	Anemia, lead poisoning, tuberculosis: Hematocrit	45%	67%	0.001	Intervention: Quality improvement intervention to improve preventive care: Practice improvement teams Specific changes to workflow were individualized by practices and included: Sending patient reminder cards Chart screening prior to patient being seen Chart flagging Using flowsheets and medical record templates Setting/population: 8 practices in North Carolina, pre-intervention n=339 patients; post-intervention n=300; children aged 24–30 months Other comments: Lead and tuberculosis screening was risk assessment and laboratory/skin testing, if indicated
	Lead screening	12%	48%	0.001
	Tuberculosis screening	50%	52%	NS
10. Dunlop AL, et al. (2007) Pre-post32	Obesity: BMI percentile documented in chart	12%	15% after Stage 1 28% after Stage 2	NS <0.05	Intervention: Provider training and support tools for obesity. 2 staged intervention: Stage 1: 2-hour provider training explaining guidelines for assessing and managing overweight and counseling framework (AIM--Advise, Identify, Motivate); training on using BMI calculator and growth charts Stage 2: 3 month supply of tools--parent screening tool/counseling guide, BMI charts, “prescription pad” for nutrition/physical activity Population/setting: 6 academic family medicine and pediatric practices in Georgia; pre-intervention n=466; Stage 1 n=538, Stage 2 n=344; children aged 2–17 years
	Nutrition and activity history	50%	56% after Stage 1 81% after Stage 2	NS <0.05
	Nutrition and activity counseling	33%	35% after Stage 1 47% after Stage 2	NS <0.05
11. Lannon CM, et al. (2008) Pre-post21	Developmental problems PEDS or ASQ	30% (received any developmental screening)	45% (using structured tool (e.g., ASQ))	NS	Intervention: Bright Futures Training Intervention Project: learning collaborative/quality improvement initiative to improve preventive care services Key practice-level changes included: Structured developmental screening (PEDS or ASQ) Chart prompts Patient recall/reminder Linkages with community agencies Used practice improvement teams and plan-do-study-act cycles Population/setting: 15 practices in 9 states; experimental n=305 patients, control n=171 patients; children aged 0–5 years Other comments: No participating practices used formal developmental screening tools pre-intervention.
12. Polacsek M, et al. (2009) Pre-post25	Obesity: BMI documented in chart Screening with previsit, self-administered tool to assess patient’s behavior around nutrition and physical activity	38% Not measured	94% 82%	<0.001 <0.001	Intervention: Learning collaborative Teams of physician, nurse and administrator from each practice; 3 1.5 day learning sessions for teams; practices set goals around nutrition and physical activity screening and counseling. Patient screening instruments and provider decision support tools for obesity management Population/setting: 12 practices in Maine; n=600 patients with visits during both pre and post intervention periods; children aged 5–18 years.
13. Shaw JS, et al. (2006) Pre-post19	Lead poisoning, anemia, tuberculosis, hypertension: Lead screening	72%	85%	0.001	Interventions: State-wide learning collaborative with 4 1-day learning sessions Practices formed teams (physician, nurse, administrator) and chose preventive care outcomes to address through practice improvements. Included periodic statewide gatherings for QI training, collaborative telephone calls, audit/feedback to practices Population/setting: 31 practices in Vermont; pre- and post-intervention n= each approx 930 patients; children aged 2–4 years Other comments: Tuberculosis and lead screening were risk assessment and laboratory/skin testing, if indicated.
	Hematocrit	70%	74%	NS
	Vision screening	62%	75%	0.013
	Tuberculosis screening	18%	39%	0.001
	Blood pressure	85%	82%	NS
14. Young PC, et al. (2006) Pre-post18	Anemia, vision problems, hypertension, obesity: Hematocrit	49%	57%	0.36	Intervention: Learning collaborative Practices chose aspects of preventive care to focus improvement efforts. Included QI methodology training, conference calls with participating practices, and chart audit/feedback Population/setting: 14 practices in Utah; pre-intervention n=544 patients; post-intervention n=517 patients; children aged 2–4 years
	Vision screening	46%	75%	0.007
	BP screening	59%	74%	0.010
	BMI recorded	32%	45%	0.078
Post intervention with and without a control group
15. Gioia PC. (2001) Post intervention without control group38	Lead poisoning: Serum lead level	Not measured	81%		Intervention: EMR with point-of-care reminders displayed on screen Population/setting: Single practice in New York; n=208 patients; children born in 1998
16. Hartmann EE, et al. (2006) Post-intervention without control group34	Vision disorders: monocular visual acuity and stereopsis 3 year olds	Not measured	70–85%		Intervention: Vision screening with specific tools for assessing monocular visual acuity and stereopsis. Provided written guidelines for referral, follow-up based on screening results. Physician and staff training, either in group sessions or one-on-one training Initiative included both Head Start and primary care practices Population/setting: 28 practices in Ohio and Tennessee; n=627 patients; children aged 3–4 years.
	4 year olds	Not measured	93–94%
17. Hull PC, et al. (2008) Post-intervention with concurrent control group39	Lead poisoning, anemia, hearing, vision: “Laboratory testing” (serum lead level and hematocrit)	74%	100%	<0.001	Intervention: Nurse-led protocol EPSDT screening, carried out by a nurse with a specific preventive care role, using protocol attached to medical record. Population/setting: One academic practice received intervention; control group was sample of children from other practices. Intervention group n=514, control n=115 patients; children aged 0–17 years
	Hearing	12%	100%	<0.001
	Vision	23%	100%	<0.001
18. Niederman LG, et al. (2007) Post-intervention with concurrent control group36	Anemia and lead poisoning: Hematocrit	77%	73%	NS	Intervention: Healthy Steps (HS) program implemented in a resident continuity clinic. Population/setting: One academic practice in Illinois; experimental n=71, control n=192 patients; children aged at least 18 months Other comments: Control group were patients in the practice but not enrolled in HS
	Serum lead level	64%	67%	NS
19. Ozer EM, et al. (2005) Post-intervention with concurrent control group31	Adolescent health risk behaviors: Adolescent health screening questionnaire	Not measured	80%	NA	Intervention: Provider training, patient questionnaire, and prompts to facilitate communication about adolescent risk behaviors 2 stage intervention: Stage 1: 8-hour provider training workshop around knowledge and skills regarding adolescent preventive care Stage 2: Introduction of patient questionnaire and provider form to screen for and document discussion and counseling regarding risky behaviors. Population/setting: 4 practices in California (2 practices received the intervention); experimental n=1717, control n=911 patients; adolescents aged 14–17 years Other comments: Control practices’ screening did not differ over study period
	Provider asked about alcohol use during visit	67%	82% after Stage 1 83% after Stage 2	<0.01 <0.001
	Provider counseled on alcohol use during visit	59%	77% after Stage 1 81% after Stage 2	<0.01 <0.001
20. Schonwald A, et al. (2009) Post intervention without cuncurrent control group30	Behavior and development problems: PEDS	Not measured	61%		Intervention: Implementation of developmental screening using PEDS 1-hour provider and staff training; physician champion who was available to answer questions from providers and staff. Offered as option for referral a second-stage screening service at the practice staffed by an educational specialist Population/setting: 1 practice in Massachusetts; pre-intervention n=338 patients, post-intervention n=278 patients; children aged 20–40 months Other comments: Use of structured developmental assessments was not routine pre-intervention; authors reported an increase in developmental concerns identified post-intervention (21% vs. 26%, p=0.05); proportion of children referred for developmental concerns did not change post intervention (10% vs 11%).
Time Series
21. Earls M, et al. (2006) Time series28	Developmental problems: ASQ	24%	62% at year 2; 76% at year 5		Intervention: Quality improvement initiative to improve child development services: Practices completed Plan-Do-Study-Act cycles Emphasized physician champion, workflow map, staff involvement, and periodic data review Part of a larger state-wide initiative that involved state-level policy changes around child developmental services Population/setting: Several practices in North Carolina; sample size was not reported Other comments: No significance testing reported
22. King TM, et al. (2010) Time series24	Development problems: PEDS or ASQ	Not measured	67% at 1 month; 85% at 9 months		Intervention: Provider and staff education, physician champion identification One-day workshop for practice teams. Practices teams were a group of three key stakeholders within each practice (physician champion, staff member, and another person). AAP-sponsored national pilot project to implement guideline-adherent developmental screening Population/setting: 17 practices from 15 states; pre- and post-intervention n≈1020 children total; children aged 8–36 months Other comments: Post-intervention screening varied among practices (33–100%); no significance testing reported
23. Pomietto M, et al. (2009) Time series26	Obesity: BMI and weight classification documented in chart	Not measured	49% at 1 month; 94% at 9 months		Intervention: Learning collaborative, combined with community and policy-level interventions. Practices participated in 3 8-hour training sessions, monthly phone calls, and practice-based coaching in QI, which included on-site visits to practices Coincided with community-level efforts to better manage chronic conditions, including obesity Population/setting: 8 practices in Washington state. Chart audits of 20 pediatric patients per month per practice were tracked for 9 months. Age range of patients was not reported. Other comments: No significance testing reported

Abbreviations:

HS – Healthy Steps

LC – Learning collaborative

BMI – Body mass index

BP – Blood pressure

QI – Quality improvement

HMO – Health maintenance organization

PEDS – Parents’ evaluation of developmental status

EMR – Electronic medical record

EPSDT – Early periodic screening, diagnosis and treatment

ASQ – Ages and stages questionnaire

AAP – American Academy of Pediatrics

RCT – Randomized controlled trial