July 17, 2018

New quality improvement study finds simple ways to ensure at-risk children are consistently given valuable health screenings

The quality improvement study, led by Toshiaki Wakai and Michael D. Fetters, was published in the Journal of the American Board of Family Medicine

small child held by mother at doctors office


Physicians have known for years that simple health screening exams given to children can help identify and mitigate long-term health issues. But it turns out those health screenings are inconsistently given to children who receive their health care services through Medicaid.

Through a quality improvement study, two researchers at the University of Michigan’s Department of Family Medicine, in association with physicians from the University of Pittsburgh and a hospital in Sapporo, Japan, identified several barriers that prevent health care workers from ordering screenings and then sought to find ways to improve the delivery of those well-child screenings.

Toshiaki Wakai, M.D.
Toshiaki Wakai, M.D., Lead Author

The paper, “Screenings during Well-Child Visits in Primary Care: A Quality Improvement Study,” was published in the July-August issue of the Journal of the American Board of Family Medicine. The study was authored by Toshiaki Wakai, M.D., Madeline Simasek, MD, Urara Nakagawa, MD, Masaji Saijo, MD, and Michael Fetters M.D., M.P.H., M.A.. Dr. Wakai is a lecturer in the University of Michigan’s Department of Family Medicine. Dr. Fetters is a professor of family medicine and co-director of the Michigan Mixed Methods Program at the University of Michigan.

Specifically, the study addressed a simple question: Is there a way to ensure that six key childhood screenings for development, anemia, lead poisoning, oral health, vision, and hearing are being consistently offered to children who are receiving Early Periodic Screening, Diagnosis, and Treatment (EPSDT) services provided under Medicaid?

Physicians view early childhood health screenings as valuable tools that can help identify and mitigate health problems before patients suffer long-term impacts as they enter adolescence and adulthood. But one study published in 2010 showed that approximately 76 percent of children in the EPSDT program did not receive screenings in one or more of those six key areas. The reasons for failing to properly order screening included confusing and unavailable forms, inadequate training, the lack of a lab facilities for drawing and analyzing blood samples, the lack of equipment for administering hearing and vision tests, and physicians simply forgetting to order the screenings.  

How the study was conducted

To gather baseline data, the study assessed how often well-child screening were being administered, identify potential barriers that prevent physicians and other health care professionals from ordering or administering well-child screenings and what could be done to improve the rate at which they were being administered. The assessment used both quantitative and qualitative data in a mixed methods approach. Quantitative data are generated from closed-ended questions using rating scales and questionnaires. Qualitative data are generated from interviews and observations.

“Many studies have been conducted to demonstrate quantitative or qualitative improvement,” Dr. Wakai said. “However, using a mixed methods approach and, specifically, a joint display as a framework to present an integrated analysis facilitated an interpretation of the quantitative and qualitative results more robust than if they had been examined separately without integration.”

READ MORE: How to train health professionals in mixed methods research

After analyzing the baseline data, study organizers conducted an intervention based on four factors—material, method, human, and mechanical. Material factors included simplifying forms and adding reminders. The method factor was meeting with medical staff to stress the importance of the screenings. Human factors included adding posters in examination rooms to remind physicians, nurses, parents, and guardians of the screenings required at various ages. Mechanical factors included improving order sets, which are templates that help medical professionals made decisions about medical conditions or procedures.

The focus of the study was children from 0-6 years old, who received Medicaid benefits during visits to the University of Pittsburgh Medical Center’s Shadyside Family Health Center between Sept. 1, 2009, and March 23, 2010. More than 180 study subjects were placed in the quantitative data category and 12 were placed in the qualitative data category.  A second assessment was given after the intervention to review if there was a change in screening rates and the way health care was delivered.

The actual data were gathered from reviews of patient charts and interviews conducted with residents, physicians, nurses, and an administrative manager who was responsible for data collection at UPMC Shadyside. The quantitative data allowed the study’s authors to measure a change in performance after the intervention, while the qualitative data were designed to give insight into why some measures did not improve following the intervention. 

Study results and recommendations

Based on a review of the results, all rates of well-child screenings went up after the intervention, however the rate of improvement was not even. The qualitative data helped to identify barriers that prevented better results. Two key barriers were a lack of facilities for drawing blood and a lack of facilities and infrastructure for vision and hearing screenings. 

The authors believe that the multifaceted intervention—combining information for both parents and guardians of the children receiving services and health care workers—was more effective than a single-item intervention because the multiple interventions may have created a synergy that combined to improve screening rates.

A secondary benefit of the study was that it spurred continuing improvements at the facility.

“This procedure prompted further continuous quality improvement activities that have been implemented to maintain the improved rates or provide a solution to these problems as LOPIR (longitudinal outpatient practice improvement rotation) projects at UPMC Shadyside Family Health Center,” Dr. Wakai said.

Those quality improvement procedures included changing the way blood was drawn for anemia screenings and changing how vision tests were given. A review of patient charts three years after the initial quality improvement study showed screening rates were continuing to improve, suggesting that the multifaceted approach led to a combination of infrastructure improvements and physician education. 

The study builds on previous quality improvement studies conducted on the delivery of health care and preventive services in family medicine. The authors expressed a hope that others will work to develop a better understanding of barriers to family medicine patient care that will lead to additional improvements and better outcomes.  

Article Citation: Wakai T, Simasek M, Nakagawa U, Saijo M, Fetters, MD. Journal of the American Board of Family Medicine, volume 31, number 4, 558-569 (July-August 2018). doi:10.3122/jabfm.2018.04.170222


Browse the latest research in preventive medicine  and mixed methods from the department of family medicine.