Implementing Reliable Screening of Co-Occurring Medical Conditions in Children with Autism Spectrum Disorders Across the Autism Treatment Network

Background: Children with an Autism Spectrum Disorder (ASD) frequently present with co-occurring medical conditions such as sleep problems and constipation. These disorders, when left untreated, may compromise not only general health, but also behavioral, developmental, and educational outcomes of individuals with ASD. Clinical care recommendations exist for sleep problems and constipation in ASD, but these guidelines are underutilized. Screening for these conditions by clinicians is inconsistent, resulting in delays in, or lack of treatment. Children with ASD require regular screening for chronic co-morbid health conditions during the course of regular health supervision visits.

Objectives: Our primary goals were to a) increase reliable screening for these medical co-occurring conditions in children with ASD by subspecialists, b) for patients with a positive screen, develop appropriate care plan(s) in partnership with families to address the problem(s).

Methods: This effort used quality improvement (QI) methodology to promote reliable screening for sleep problems and constipation in a network of 15 medical centers. The Model for Improvement, developed by Associates in Process Improvement (API), was used to frame the work. Specific Measureable Actionable Realistic Time (SMART) aims were developed focusing on increasing screening, and documentation of constipation and sleep problems. Interventions were tested to improve the reliability of screenings and development and documentation of care plans. These included education sessions for providers and clinic staff, modifications to medical records procedures, and personalized interventions for low performing providers. The sites randomly selected 20 charts per month for review to measure documentation of screening and care plans. Results: Over a one year period, the majority of the 15 Network sites (13 of 15) reached at least 85% reliability in screening for sleep problems and constipation in children with ASD; and development and documentation of care plans for those with a positive screen. Preliminary outcome data suggests a majority of children showed improvement in these co-occurring conditions with early identification and first line intervention (75% constipation, 61% sleep).

Conclusions: This work describes a multi-institutional QI collaborative using a modified Institute for Health Improvement (IHI) Breakthrough Series to improve the identification and treatment of medical conditions seen frequently in individuals with ASD. Improvement was documented at all sites, with several meeting the pre-determined goals and most reaching high levels (85%) if not reaching the goal of 95%. Preliminary data indicated that the improvement in the clinical process was having an impact on the symptoms of those patients with identified conditions. QI methodology is an effective framework to impact change across a network of providers in unique healthcare settings. This effort can provide networks a framework to systematically implement standards of care across multiple medical settings.