Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

We are interested in the comparative effectiveness of different preventative health screening tools for early diagnosis of health and developmental concerns in children. We are particularly interested in the comparative effectiveness of EPSDT and AAP’s Bright Futures and also interested to see if there are other early screening comparators routinely used outside of the US. In addition we would like to know if there are some screening components of EPSDT and/or Bright Futures for which there is higher value and more evidence for return on investment in desired outcomes?

EPSDT was established in 1967 as a means “to discover, as early as possible, the ills that handicap our children" and to provide "continuing follow up and treatment so that handicaps do not go neglected"(source - http://www.hrsa.gov/epsdt/overview.htm) and is required to be used by state Medicaid programs. Under the Deficit Reduction Act of 2005 (DRA, enacted February 2006), states were given the option to modify the approach to delivery of services to children enrolled in Medicaid. As such some states have adopted the Bright Futures screening tool developed by AAP. Both of these tools are used by physicians and others to diagnose developmental and health concerns that could affect children’s health and performance in school.

Additional information about EPSDT screening service areas can be found here http://www.cms.hhs.gov/MedicaidEarlyPeriodicScrn/02_Benefits.asp#TopOfPage

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

See #1 above

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Patients of interest include children under the age of 10, with particular interest in children under the age of six. EPSDT is very prescriptive about what test should be done at what ages and Bright Futures has different periodic screening guidelines – we are interested in knowing what the evidence is for what screening and diagnosis test for which years.

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

We are particularly interested in MEDICAID and SCHIP populations.

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

Early and timely diagnosis of physical, emotional and developmental concerns in children can greatly impact a child’s ability to learn and grow.

Appropriately implemented early diagnosis and screening can identify children that would benefit from early intervention to meet identified risks.

Describe any health-related risks, side effects, or harms that you are concerned about.

We are interested in whether or not there are any harms associated with the required EPSDT or Bright Futures screening tests. For example, if they are done too frequently, does it hinder children from going to the doctor later on in life? Are there any risks that outweigh the benefits of required screening tests.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Arthritis and nontraumatic joint disorders
• Depression and other mental health disorders
• Developmental delays, attention-deficit hyperactivity disorder, and autism
• Diabetes mellitus
• Functional limitations and disability
• Obesity
• Pulmonary disease/asthma

AHRQ Priority Populations

• Low income groups
• Children
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• State Children's Health Insurance Program (SCHIP)

Importance

Describe why this topic is important.

As indicated in question #1 EPSDT is required by states and as a result millions of State Medicaid dollars are spent on these exams on an annual basis. We are interested in learning about the comparative effectiveness of these tests so that we can insure that we are making the best use of limited Medicaid resources and targeting them towards methods and tools that are the most effective and produce the best outcomes for children.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

This has been an on-going concern for Medicaid programs. We think this topic is timely given the current emphasis on health care reform and comparative effectiveness as well as this program having been in effect for over 40 years and in need or review. States are under pressure to increase screenings and the burden of the current screening protocol makes it very difficult for PCP’s to organize their schedules (given the reimbursement). EPSDT appointments are time intensive and often patients in this population do not keep the appointments for multiple reasons inherent to their life situation. We are very interested in getting recipients the services they need in the most efficient and cost effective manner possible.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

State Medicaid programs are required by law to ensure that the screenings are conducted on the children enrolled in their state and as a result of new legislation in 2005, are able to modify our approach to meeting these mandates. However, states do not have good evidence to determine best practices. Push back from local pediatricians on the EPSDT requirements and the payment mechanisms that limit payment for the tests make it even more critical that we are requiring tests that are evidence based. This in turn can assure that the resources are used to the greatest benefit for the covered children and the state population overall. It may prove easier to get physicians, parents and guardians all “on board” with testing if the evidence base supports such work.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

It will help us determine what, if any modifications we should be implementing in our state(s) under the DRA. It would also assist us to ensure that well child screenings are based on, and delivered by Medicaid staff, Contractors and providers, using the best available evidence.

Describe the timeframe in which an answer to your question is needed.

As soon as possible.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

See Question #3a. above

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

It will help us determine what, if any modifications we should be implementing in our state(s) under the DRA. It would also assist us to ensure that well child screenings are based on, and delivered by Medicaid staff, Contractors and providers, using the best available evidence.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

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