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Pediatricians are now being asked to add depression, HIV, and dyslipidemia screening to preventive care visits, but guideline authors say the changes will help improve efficiency.
The American Academy of Pediatrics (AAP) has released its new Recommendations for Preventive Pediatric Health Care, but the new guidelines are meant to add efficiency-not time-to already packed preventive care visits.
The update-the third in 21 months-represents AAP’s new strategy of updating its guidance in “real time” to keep abreast of changes.
“A significant concern that many pediatricians express to the academy is that there are already too many things to do within the limited time frame of a preventive care visit, and now with this approach, more stuff is being piled on,” says Geoffrey Simon, MD, a pediatrician at Nemours Children’s Health System in Wilmington, Delaware, who served on AAP’s Committee on Practice and Ambulatory Medicine, which crafted the recommendations. “The academy and the pediatricians on the committees in charge of the periodicity schedule are actively practicing primary care pediatricians who have to use this day-to-day. One of the key things that our committee emphasizes is that these additional recommendations should not add to the pediatrician’s time during the visit, and the goal is to actually increase efficiency of the visit.”
The guideline updates include adding a number of evidence-based screenings to the preventive care visit, while vision screenings have been dropped from the recommendations in lieu of a risk assessment.
The AAP is also working to develop better tools to help pediatricians accomplish the changes outlined in the guideline, Simon says.
“The academy is working to include suggestions on tools and methodologies that are cost and time effective as well, not just telling pediatricians to ‘do this’ and having to navigate logistics, but also ‘here’s a tool to do it with, this is an effective way to use the tool, this is what it costs and here’s the information you need to code and bill for this,’” he says.
As for the guidelines, the only recommendation for less screening was for routine vision screening, which is no longer recommended for 18-year-old patients.
“This reflects the data showing it is unlikely for an 18-year-old [patient] to have a new asymptomatic significant visual impairment present at this age,” says Simon. “What I think is more significant than the change in the vision screening for 18-year-olds is the recommendation to consider instrument-based vision screening in 12- and 24-month-old children in addition to the current measure of acuity using optotype charts starting at age 3- to 4-years-old.”
Simon says AAP and a number of ophthalmology experts are now advocating earlier detection of vision problems using newer screening instruments like autorefractors.
“The AAP recognizes that the costs and coverage for using these devices are presently barriers to universal adoption by all pediatricians, but improved technologies, lower costs, and better data showing these devices are effective means to screen children at an even younger age, particularly in the earlier detection of amblyopia, were the factors considered in making the recommendations,” he says.
For oral health, AAP is recommending added fluoride varnish applications for children aged 6 months to 5 years. Dental cavities are the top chronic disease affecting young children, and the recommendation was based on the updated US Preventive Services Task Force recommendation finalized in 2014 that was endorsed by AAP. The lag in the adoption of this recommendation, Simon says, was that a medical code-previously only a dental code existed-had to be created for physicians to apply the varnish so that insurance companies would recognize the service.
“Many state Medicaid programs had been paying physicians using the dental codes for applying fluoride varnish for several years, though this varied state-to-state,” Simon says.
In regard to parents concerns about the necessity of the varnish, Simon says it can be very valuable in early prevention of cavities without the risk of oral fluoride supplements.
“The rationale for having the pediatrician apply the fluoride is that many infants and children don’t have access to a dental home at a young age. There may not be any periodontists or dentists who care for this age group in a community. A child may not have dental insurance in the first few years of life–it is not unusual for families to not add infants to their dental insurance plans and if they miss an annual enrollment period it may be over a year before they have another opportunity to add coverage,” he says. “By having this quick and inexpensive service done in the pediatrician’s office, the fluoride varnish is a way to promote oral health until the child establishes a dental home. The fluoride varnish also does not have the risk of dental fluorosis as is a potential complication from oral fluoride supplements.”
A number of screenings were also recommended by the committee for addition to preventive care.
Depression screenings were added to address early intervention and recognition considering suicide is the leading cause of death among adolescents.
“The goal here was to introduce easy to use validated, self-administered screening tools such as the PHQ2/9, which could be completed by the patient prior to the visit,” Simon says. “These did not require a physician to do the screening, and if positive, concerns about depression could be identified at the beginning of the appointment to allow better use of physician time. The goal was to again remove selection bias as well as avoid the ‘by the way…’ when the pediatrician’s hand is on the doorknob at the end of the checkup.”
The committee also recommended screening for dyslipidemia in children aged between 9 and 11 years to address the growing childhood obesity problem.
“This has gotten the most pushback, but the changes made reflect updated recommendations from the NIH [National Institutes of Health] National Heart Lung and Blood Institute published in late 2013, with the intent to make it easier by doing universal testing on 9-to 11-year-old [patients],” Simon says. “The previous recommendation of testing based on risk factor assessment was cumbersome and not sufficiently sensitive.”
Routine screenings for cervical dysplasia and human immunodeficiency virus [HIV] were also amended on the recommendation list. Cervical dysplasia screenings are now recommended at age 21 years and beyond instead of a risk assessment between ages 11 and 21, since typical cervical changes in adolescents could yield false positives and lead to unnecessary treatments and procedures. Simon says this recommendation was made for several years prior to its adoption by both AAP and the American College of Obstetricians and Gynecologists.
“My observation is that most pediatricians were aware of these recommendations well before the periodicity schedule was updated and was a prime example of why the recommendations would be updated more regularly,” Simon says. “This is an example of removing a service from the recommendations that results in less time and work for the pediatrician.”
Universal HIV screening was another addition, and recommended for children aged between 16 and 18 years. The AAP says federal statistics have revealed that 1 in 4 new HIV infections occur in the 13 to 24 years age group, and that 60% of children and adolescents with HIV don’t even know they’re infected. The new recommendation reflects previous suggestions from both AAP and the Centers for Disease Control and Prevention, says Simon.
“By making it universal, the intention is to remove physician and healthcare provider bias and assumptions in terms of whom to test, particularly as HIV infection is something that now can be treated and managed as a chronic infection if detected early,” he says.
Other added recommendations include risk assessments at 15 and 30 months of hematocrit and hemoglobin to detect anemia, a screening for adolescent drug and alcohol use, and a screening for congenital heart disease using pulse oximetry.
The full updated guideline is published in the January 2016 issue of Pediatrics and includes links to additional research related to each recommendation.