Increasing Use of M-CHAT-R/Follow-up in Pediatric Care through Clinician Participation in a Maintenance of Certification Quality Improvement Project

Background:  The American Academy of Pediatrics recommends that all children be screened for Autism Spectrum Disorder (ASD) at ages 18 and 24 months using valid tools. Screening for ASD is critical for earlier identification and intervention to improve outcomes, yet routine screening is not uniformly implemented. Many practice-level barriers prevent the efficient and timely use of recommended ASD screens such as the Modified Checklist for Autism in Toddlers-Revised with the required Follow-up Interview (M-CHAT-R/F). These barriers to screening are often the target of Quality Improvement (QI) projects in pediatric care. Part 4 of the American Board of Pediatrics (ABP) required physician Maintenance of Certification (MOC-4) program—Improving Professional Practice—aims to increase physician knowledge of quality improvement methods and engagement in QI projects to improve care. One accredited MOC-4 program offered through the Center for Promotion of Child Development through Primary Care targets barriers to routine ASD screening among physicians using the affiliated web-based platform CHADIS, which supports developmental screening, clinical decision making, and patient engagement in pediatric care.

Objectives:  Compare 6-month baseline average M-CHAT-R/F screening rates to 6-month post-MOC QI project rates to assess influence of physician participation in an MOC project on improving ASD screening.

Methods:  All physicians enrolled in this MOC QI project completed a 10 minute online educational module on autism screening, diagnosis, and intervention. Physicians also met with coaches monthly for one hour to identify barriers to screening in his/her practice and plan QI activities to overcome them using the Plan-Do-Study-Act framework. Coaches reviewed run charts tracking the impact of QI activities on ASD screening rates with physicians. To assess practice-level impact of MOC-related QI activities, the number of M-CHAT-R/Fs completed using the CHADIS system was examined for the 6 months prior compared to the 6 months following MOC enrollment.

Results:  MOC participation and M-CHAT-R/F screening data was analyzed from 138 clinicians representing 47 practices ranging from solo practitioner to multi-physician hospital settings across the U.S. On average, these physicians reported 24 years of clinical experience. Before MOC participation, 71% reported routinely screening for ASD at ages 18 and 24 months. Many barriers to appropriate use of the M-CHAT-R/F were identified, including inefficient office workflows, failure to administer follow-up interviews for all positive screens, and limited task-sharing and communication between clinical support and administrative staff. In the 6 months prior to MOC enrollment, an average of 21 M-CHATS-R/Fs were completed per month across practices. After MOC enrollment, the average number of M-CHAT-R/Fs completed in the CHADIS system increased to 30 per month, a 43% increase. Percent change in screening between baseline and follow up was positive among all enrolled practices and ranged from 12% to 180% increases in screening after implementing the Plan-Do-Study-Act QI framework and tailored improvement activities.

Conclusions:  Physician participation in the MOC-4 quality improvement project offered through CHADIS increased rates of M-CHAT-R/F use across a 6-month period. Future projects engaging physicians in quality improvement at the practice level should be considered to reduce barriers to implementing routine ASD screening in pediatric care.