Marks K, et al. Lowering Developmental Screening Thresholds and Raising Quality Improvement for Preterm Children. Pediatrics. 2009;123(6); 1516–1523

OBJECTIVES: To determine: 1) if preterm children were referred, identified and received early intervention (EI)/ early childhood special education (ECSE) services at rates equivalent to term children after implementation of a universal, periodic Ages and Stages Questionnaire (ASQ) surveillance and screening system; 2) if pediatricians sufficiently lowered their screening thresholds with preterm children; and 3) if quality improvement opportunities exist.

PATIENT AND METHODS: Secondary analysis was performed on 64 lower-risk, mostly late-preterm and 1363 term children who originally presented to their 12- or 24-month well- visits. Higher-risk preemies already involved with an EI agency/ identified with a delay were excluded. Board-certified pediatricians (N = 18), and nurse practitioners (N = 2), blind to the ASQ results, were secondary participants. Differences between preterm and term developmental agency referrals were examined comparing Pediatric Developmental Impression to the ASQ under natural clinic conditions using a combined in-office or mail-back data collection protocol. Medical record and county EI/ECSE follow-up outcomes were conducted at 36 to 60 months.

RESULTS: At 12 and 24 months, preterm (versus term) referral rates were 9.5% (versus 5.6%) with Pediatric Developmental Impression and 26.2% (versus 8.1%) with the ASQ. By 36 to 60 months, 37.5% of preterm (20.8% term) children were referred to EI/ECSE; of which, 50.0% of preterm (42.4% term) children were eligible for services, 54.2% of preterm children were identified with a developmental-behavioral disorder and 29.2% of preterm (20.8% term) children did not follow-up. For ASQ-only preterm referrals, 55.6% were subsequently diagnosed with a developmental delay and/or disorder. Preterm children were ∼2 times more likely to be eligible than term children.

CONCLUSIONS: Combined referral, quality improvement and outcome data suggests that clinicians should lower their threshold for administering a psychometrically sound developmental screen when providing surveillance for ex-preemies. Quality improvement opportunities exist with diligent developmental surveillance and a more collaborative, standardized, reliable and interpersonal referral process.