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 evidentiary foundation of various screening and diagnosis guidelines focusing on wellness and early identification of health and developmental concerns in children and adolescents.

We are also interested in whether or not there are screening areas covered by EPSDT and/or Bright Futures for which there is higher value and more evidence for return on investment in desired outcomes?

Currently EPSDT, and modification of EPSDT allowed under the Deficit Reduction Act of 2005 (DRA), are required by state Medicaid programs and serve as the standard for screening and diagnosis of children’s early health concerns and developmental problems. 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). Under the DRA, enacted February 2006, states were given the option to modify the approach to the delivery of services to children enrolled in Medicaid. As such, some states have adopted the Bright Futures screening tool developed by the AAP. Both of these tools are used by clinicians to diagnose developmental and health concerns. Other broad and condition specific screening and diagnostic guidelines are in place and recommended by states, USPSTF, health care plans, associations and other countries (examples of some of these guidelines are provided in question 3 below). A study of the state of evidence on screening and wellness guidelines is needed.

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:

We are interested in knowing the evidence base is for various screening and wellness guidelines for children especially as it relates to the identification and diagnosis of health, development and mental health concerns. Are screening and diagnostic tools which are currently in use evidence based? What are the benefits and limitations of these tools? What is the level of confidence or evidence rating for these tools (e.g. are guidelines based on primary research, systematic reviews, expert opinion or consensus?) Examples of current child wellness guidelines follows (this list is not meant to be exhaustive) –

• AMA - Guidelines for Adolescent Preventive Services (GAPS)
• Medicaid - EPSDT http://www.cms.hhs.gov/MedicaidEarlyPeriodicScrn/02_Benefits.asp#TopOfPage

and http://www.cms.hhs.gov/Manuals/PBM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS021927

• AAP- Bright Futures – Recommendations for Preventative Pediatric Health Care
• AAFP –Summary of Recommendations for Clinical Preventative Services http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/CPS/rcps08-2005.Par.0001.File.tmp/CPSapprovedApril2009.pdf

Mountain State Blue Cross Blue Shield. (2009) Pediatric and Adolescent Preventive Schedule: Ages 7 through 18 years. Retrieved August 11, 2009 at https://www.msbcbs.com/PDFFiles/healthwatch/2009_PH_Pediatric_Guideline_7-18.pdf

Michigan Quality Improvement Consortium. Routine preventive services for children and adolescents (ages 2-18). Southfield (MI): Michigan Quality Improvement Consortium; 2007 May

Michigan Quality Improvement Consortium. Routine preventive services for infants and children (birth-24 months). Southfield (MI): Michigan Quality Improvement Consortium; 2007

American Dietetic Association (ADA). Pediatric weight management evidence-based nutrition practice guideline. Chicago (IL): American Dietetic Association (ADA); 2007 Jun

Birmaher B, Brent D, AACAP Work G

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.

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 and the application of guideline differences among these populations compared to non-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 conditions in children can greatly impact a child’s ability to learn and grow and to be successful in school and later in work.

Appropriately implemented early diagnosis and screening can identify children that would benefit from early intervention and treatment to prevent long term health problems.

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

We are interested in whether there are harms associated with testing outlined in the guidelines particularly with guidelines that are not evidence based and/or when there are conflicting guideline recommendations. Are there harms to children and/or their parents when different guidelines conflict with each other?

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

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.. A report on the evidence for these guidelines will serve to inform public payers, health care providers/physicians and parents of the evidence as it relates to EPSDT screening of 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 and given the current emphasis on health care reform and comparative effectiveness a review of the evidence on guidelines is timely. Some of the guidelines have been in effect for over 40 years and other guidelines are based on limited or no evidence.

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 the new law in 2005 we are able to modify our approach. 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 children and the state 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 program and to assess the effectiveness of the program in meeting its objectives. It would 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 program and to assess the effectiveness of the program in meeting its objectives. It would 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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