PEDIATRICS Vol. 123 No. 6 June 2009, pp. 1516-1523 (doi:10.1542/peds.2008-2051)
ARTICLE |
Lowering Developmental Screening Thresholds and Raising Quality Improvement for Preterm Children
a Department of Pediatrics, PeaceHealth Medical Group, Eugene, Oregon
b Division of General Pediatrics, Department of Pediatrics, School of Medicine, Oregon Health and Science University, Portland, Oregon
c Faculty of Community Services, School of Child and Youth Care, Ryerson University, Toronto, Ontario, Canada
d Early Childhood Coordination Agency for Referrals, Evaluations and Services in Lane County, University of Oregon, Eugene, Oregon
OBJECTIVES. Our goal was to determine if (1) preterm children were referred, identified, and received early-intervention/special education services at rates equivalent to term children after implementation of a universal, periodic Ages & Stages Questionnaire screening and surveillance system, (2) pediatricians sufficiently lowered their screening thresholds with preterm children, and (3) quality-improvement opportunities exist.
PATIENT AND METHODS. Secondary analysis was performed on 64 lower-risk, predominantly late-preterm and 1363 term children who originally presented for their 12- or 24-month well-child visits. Higher-risk premature infants already involved with an early-intervention agency or identified with a delay were excluded. Board-certified pediatricians (n = 18) and nurse practitioners (n = 2), who were blind to the Ages & Stages Questionnaire results, were secondary participants. Differences between preterm and term early-intervention agency referrals were examined by comparing pediatric developmental impression to the Ages & Stages Questionnaire under natural clinic conditions using a combined in-office or mail-back data-collection protocol. Medical chart and county early-intervention or special education agency follow-up outcomes were conducted at 36 to 60 months.
RESULTS. Preterm referral rates were 9.5% (term: 5.6%) with pediatric developmental impression and 26.2% (term: 8.1%) with the Ages & Stages Questionnaire. In follow-up, 37.5% of preterm and 20.8% of term children received referrals, of which 50.0% of preterm and 42.4% of term children were eligible for services, 54.2% of preterm children were identified with a developmental-behavioral disorder, and 29.2% of preterm and 20.8% of term children did not follow-up. For the Ages & Stages Questionnaire, only preterm referrals (55.6%) were subsequently identified with an eligible delay or disorder or both. Preterm children were 
2 times more likely to be eligible than term children.
CONCLUSIONS. Combined referral, quality-improvement, and outcome data suggest that clinicians should lower their threshold for administering a quality developmental screening instrument when providing surveillance for premature infants. Quality improvement exists with diligent developmental surveillance and a standardized, reliable, but more interpersonal referral process.
Key Words: Ages & Stages Questionnaire • developmental delay • developmental screening • developmental surveillance • early intervention
Abbreviations: EI—early intervention • ASQ—Ages & Stages Questionnaire • ECSE—early childhood special education • WCV—well-child visit • QI—quality improvement • AAP—American Academy of Pediatrics • PDI—pediatric developmental impression • ADHD—attention-deficit/hyperactivity disorder • CI—confidence interval
Accepted Sep 17, 2008.
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