Routine Screening In Primary Care Research Articles

Family Medicine Team Perspectives on Screening for Health-Related Social Needs.

Social drivers of health (SDH) strongly influence health outcomes and disparities. Although systemic level change is vital to address the disparities driven by SDH, it is also crucial that health care organizations develop the ability to care for patients in a manner that accounts for social factors and their influence on patient health. Although primary care is a natural fit for health-related social needs (HRSN) screening and intervention, significant barriers can impede primary care's effectiveness in this area. We conducted 3 focus groups with family medicine clinicians, clinical staff, and social care workers in an academic medical center using a semistructured discussion guide to explore current practices, perceived benefits, barriers, and potential opportunities and approaches for integrating routine HRSN screening in primary care. 3 primary themes emerged from the focus groups. They included 1) the barriers to routine screening in primary care, including time, workload, emotional burden, patient factors, and team members' fear of inadequacy of resources or their own ability; 2) the importance and benefit of HRSN screening, including the opportunity to improve patient care through increased care team awareness of the patient's context, interventions to address HRSN, and improved relationships between the care team and the patient; and 3) recommendations for implementing routine screening in primary care, including opportunities to optimize workflow and technology, the importance of an electronic medical record (EMR)-integrated resource database, and the centrality of teamwork. Family medicine health care teams embrace the importance of HRSN screening and the potential for positive impact. However, there are vital barriers and considerations to address for HRSN screening to be effectively integrated into primary care visits.

Adolescent Depression Symptom Trajectories Detected Via Universal Screening in Pediatric Primary Care.

Unique trajectories of adolescent depression symptoms have been identified, yet less is known about whether such patterns translate to real-world clinical settings. Because annual adolescent depression screening is becoming more prevalent in primary care, we examined whether longitudinal patterns of depression symptoms documented in the developmental psychopathology literature can also be detected via routine screening in primary care and explored how membership in the identified trajectories varied based on concurrent suicide risk and sociodemographic factors. A total of 1,359 adolescents aged 12-16 years old at the first timepoint were included in the current analyses. These adolescents completed three depression screeners during their well-visits in a large pediatric primary care network between November 15, 2017 and February 1, 2020. Retrospective electronic health record data were extracted, including sociodemographic variables and depression screening results. Dynamic functional time series clustering results indicated the optimal number of clusters was five. The five depression symptom trajectories were: (1) A-Shaped (i.e., relatively low depression symptoms at Time 1, a substantial increase in symptoms at Time 2, and a return to low symptoms at Time 3), (2) Increasing, (3) Low-Stable, (4) High-Decreasing, and (5) Low-Decreasing. Cluster differences in suicide risk largely mapped onto depression symptom levels at each assessment. We found cluster differences based on practice location, insurance type, and adolescent race. The symptom trajectories observed in this study resemble those found in the developmental psychopathology literature, though some key differences were noted. Findings can inform future research and symptom monitoring in primary care.

Screening for undiagnosed atrial fibrillation using a single-lead electrocardiogram at primary care visits: patient uptake and practitioner perspectives from the VITAL-AF trial

BackgroundScreening for atrial fibrillation (AF) is appealing because AF is common, when undiagnosed may increase stroke risk, and stroke is preventable with anticoagulants. This study assessed patient and primary care practitioner (PCP) acceptability of screening for AF using a 30-s single-lead electrocardiogram (SL-ECG) during outpatient visits.MethodsSecondary analyses of a cluster randomized trial. All patients ≥ 65 years old without prevalent AF seen during a 1-year period and their PCPs. Screening using a SL-ECG was performed by medical assistants during check-in at 8 intervention sites among verbally consenting patients. PCPs were notified of “possible AF” results; management was left to their discretion. Control practices continued with usual care. Following the trial, PCPs were surveyed about AF screening. Outcomes included screening uptake and results, and PCP preferences for screening.ResultsFifteen thousand three hundred ninety three patients were seen in intervention practices (mean age 73.9 years old, 59.7% female). Screening occurred at 78% of 38,502 individual encounters, and 91% of patients completed ≥ 1 screening. The positive predictive value of a “Possible AF” result (4.7% of SL-ECG tracings) at an encounter prior to a new AF diagnosis was 9.5%. Same-day 12-lead ECGs were slightly more frequent among intervention (7.0%) than control (6.2%) encounters (p = 0.07). Among the 208 PCPs completing a survey (73.6%; 78.9% intervention, 67.7% control), most favored screening for AF (87.2% vs. 83.6%, respectively), though SL-ECG screening was favored by intervention PCPs (86%) while control PCPs favored pulse palpation (65%). Both groups were less certain if AF screening should be done outside of office visits with patch monitors (47% unsure) or consumer devices (54% unsure).ConclusionsThough the benefits and harms of screening for AF remain uncertain, most older patients underwent screening and PCPs were able to manage SL-ECG results, supporting the feasibility of routine primary care screening. PCPs exposed to a SL-ECG device preferred it over pulse palpation. PCPs were largely uncertain about AF screening done outside of practice visits.Trial registrationClinicalTrials.gov NCT03515057. Registered May 3, 2018.

High Rates of Adolescent Depression and Suicide Risk Detected by Routine Screening in Primary Care

The USPTF recommends screening adolescents ≥12 years-old for depression during primary care visits. To anticipate and provide appropriate mental-health

Primary aldosteronism is a public health issue: challenges and opportunities.

A significant proportion of hypertension (potentially more than 5% in the general population) is due to primary aldosteronism (PA) which carries a worse prognosis when compared with blood pressure-matched essential hypertension. Effective targeted treatments are available which mitigate many of the cardiovascular complications of untreated PA. Despite this, the detection rate of PA in primary care is sub-optimal. In this review, we explore the challenges contributing to the under-diagnosis of PA in the community, including uncertainties regarding its actual prevalence. In order to detect PA early and offer targeted treatment before adverse cardiovascular consequences develop, routine screening for PA at the time of a diagnosis of hypertension would seem desirable. However, this is limited by a lack of studies to establish whether routine screening in primary care is cost-effective. Newer techniques are also being developed which could lessen the complexity of diagnosing PA. Most importantly, a dramatic increase in awareness of PA, as a treatable cause of hypertension, is needed amongst clinicians who manage hypertension.

Novel diagnostic technologies for clinical and frontline use: Advanced diagnostics based on molecular markers and analysis technologies has been improving diagnosis across a wide range of diseases.

Misdiagnosis is a major problem at all levels of health care causing unnecessary pain or even death as it prevents efficient, timely, and adequate treatment. In the case of infectious diseases, for instance, identification of the wrong pathogen might lead to incorrect prescription of antibiotics. While reliable data on the full extent of misdiagnosis are elusive, some evidence of the problem's scale came from a meta‐analysis of deaths within US intensive care units (ICUs), which found that 40,500 adult patients in the USA may die each year as a result of a misdiagnosis [1]. An earlier, more comprehensive, study based on searching the MEDLINE (1950–2007) and EMBASE (1980–2007) electronic databases for articles about diagnostic error or delay in primary care also found that misdiagnosis was a significant issue, although the reasons varied with each condition [2]. Moreover, many diseases, in particular rare diseases, are hard to diagnose as physicians are often unfamiliar with the symptoms; alternatively, the symptoms might be vague or untypical, as can happen with some autoimmune disorders. Many cancers in their early stages do not even show any symptoms, which prevents timely and effective treatment. There are also complex disorders that present highly varied symptoms that can lead doctors in the wrong direction, at least at first. Not surprisingly, there is an immense interest in molecular‐level diagnostics that promise to deliver far more accurate and rapid diagnoses without relying on interpreting symptoms. While this can raise new challenges, such as poor‐quality samples or analyzing complex data sets, molecular diagnostics has made progress across a range of clinical conditions, including infectious diseases and some cancers, through identification of characteristic molecular markers. A wide variety of diseases could also be diagnosed using next‐generation sequencing (NGS), including solid cancers or rare diseases of genetic origin. NGS …

Routine primary care screening for intimate partner violence and other adverse psychosocial exposures: what's the evidence?

BackgroundFamily physicians and other primary care practitioners are encouraged or expected to screen for an expanding array of concerns and problems including intimate partner violence (IPV). While there is no debate about the deleterious impact of violence and other adverse psychosocial exposures on health status, the key question raised here is about the value of routine screening in primary care for such exposures.DiscussionSeveral characteristics of IPV have led to consideration for routine IPV screening in primary care and during other healthcare encounters (e.g., emergency room visits) including: its high prevalence, concern that it may not be raised spontaneously if not prompted, and the burden of suffering associated with this exposure. Despite these factors, there are now three randomized controlled trials showing that screening does not reduce IPV or improve health outcomes. Yet, recommendations to routinely screen for IPV persist.Similarly, adverse childhood experiences (ACEs) have several characteristics (e.g., high frequency, predictive power of such experiences for subsequent health problems, and concerns that they might not be identified without screening) suggesting they too should be considered for routine primary care screening. However, demonstration of strong associations with health outcomes, and even causality, do not necessarily translate into the benefits of routine screening for such experiences. To date, there have been no controlled trials examining the impact and outcomes – either beneficial or harmful - of routine ACEs screening. Even so, there is an expansion of calls for routine screening for ACEs.SummaryWhile we must prioritize how best to support and intervene with patients who have experienced IPV and other adverse psychosocial exposures, we should not be lulled into a false sense of security that our routine use of “screeners” results in better health outcomes or less violence without evidence for such. Decisions about implementation of routine screening for psychosocial concerns need similar rigorous debate and scrutiny of empirical evidence as that recommended for proposed physical health screening (e.g., for prostate and breast cancer).

TARGETING DEMENTIA SCREENING IN PRIMARY CARE SITES

With potentially promising therapeutics on the horizon, there is increasing interest in implementing routine dementia screening programs for early detection. Critics have cited since no treatments are currently available, there is no benefit to screening, and that screening itself, may lead to harm. The Indiana University Cognitive Health Outcomes Investigation of the Comparative Effectiveness of dementia screening (CHOICE) study is currently assessing if routine screening in primary care is associated with benefits or harms. Quality of life, depression, and anxiety are measured at 12 months post screening to determine screening impact. A randomized controlled trial of 4,000 older primary care patients in Indiana. Patients are randomized to receive dementia screening or no dementia screening. Patients are screened with the Memory Impairment Screen (MIS) at baseline either by phone (MIS-T; rural sites) or in person (MIS; urban sites). The positive screen rate varied significantly by site. We performed a logistic regression analysis to determine if patient factors associated with positive screening explained these varying rates. As of December 31, 2015 3,157 patients had been enrolled and 1,585 were randomized to the screening arm. Overall, rates of positive screening tests were 4.6%; lower than the expected and lower than published literature. Results from a logistic regression analysis showed that males (OR=1.97; 95% CI =1.16-1.33), patients age ≥80 years (OR=2.51; 95% CI =1.37-4.59), those with lower education (OR=3.61; 95% CI =1.50-8.70), and who self-reported forgetfulness on the Health Utility Index (OR=4.69; 95% CI =1.51-14.55) had significantly increased odds of screening positive for dementia. Even after adjusting for the demographic differences across recruitment sites, there was a marginally significant difference between sites. Specifically, the two sites where MIS administration was in person had marginally (p=0.096) higher odds (ORs=2.37 and 2.16) of screening positive than the site where administration was by phone. The success of dementia screening programs in primary care will depend on the target population, choice of screening instrument, and mode of administration. These strategies will likely minimize any harm associated with screening (negative and false positive screens) as well as maximize the benefit of detecting early cases.

Implementation of marijuana and drug screening with depression and alcohol screening: results from a pilot study integrating behavioral health screening into routine primary care

Background Routine primary care screening for depression and alcohol use is widely recommended. Benefits of screening for marijuana and drug use are less clear, but might identify patients whose drug use complicates their health. As a result, leaders of a large integrated healthcare system in a U.S. state, where recreational marijuana use was recently legalized, implemented screening for marijuana and drug use as part of a pilot of behavioral health integration in primary care. The objective is to describe the prevalence of screening and further assessment of marijuana and drug use compared to depression and alcohol misuse during early implementation.

Prevalence of Autism Spectrum Disorder in Children Referred for Diagnostic Autism Evaluation.

Increased public awareness of autism spectrum disorders (ASD) and routine screening in primary care have contributed to increased requests for diagnostic ASD evaluations. However, given the scarcity of subspecialty autism diagnostic resources, overreferral of children suspected of having ASD may be contributing to long waiting lists at tertiary care autism centers and delaying diagnosis for those children who truly have ASD. To determine whether children are being excessively referred to ASD-specific diagnostic clinics, our objective was to determine the prevalence of true ASD diagnoses in children referred for diagnostic ASD evaluation. Charts of all patients referred to a regional autism center between April 2011 and August 2012 for suspicion of a possible ASD were retrospectively reviewed and demographic and clinical diagnoses abstracted. Only 214 of 348 patients evaluated (61%) received an ASD diagnosis. Thus, concerns about autism are not confirmed by an ASD diagnosis in a significant number of children.

Screening and Prevention Measures for Melanoma: Is There a Survival Advantage?

Controversy has emerged over the past decades regarding the value and impact of melanoma screening to detect early stage disease for improved prognosis. Those questioning the benefits of prevention efforts base their arguments on the absence of prospective, randomized studies demonstrating decreased melanoma mortality to justify the cost associated with screening and educational campaigns. For those in favor of melanoma screening, the lack of proven survival benefit is not a justification to abandon this approach, but rather a reflection of the lack of resources necessary to conduct a long-term trial. In 2009, the US Preventive Services Task Force (USPSTF)report did not recommend routine primary care screening for the general population given the absence of evidence. However, since the USPSTF report, a series of new studies are available, which support the potential benefit of screening and have the potential to significantly impact current policies regarding skin cancer screening, particularly for melanoma.

Yield of Practice-Based Depression Screening In VA Primary Care Settings

Many patients who should be treated for depression are missed without effective routine screening in primary care (PC) settings. Yearly depression screening by PC staff is mandated in the VA, yet little is known about the expected yield from such screening when administered on a practice-wide basis. We characterized the yield of practice-based screening in diverse PC settings, as well as the care needs of those assessed as having depression. Baseline enrollees in a group randomized trial of implementation of collaborative care for depression. Randomly sampled patients with a scheduled PC appointment in ten VA primary care clinics spanning five states. PHQ-2 screening followed by the full PHQ-9 for screen positives, with standardized sociodemographic and health status questions. Practice-based screening of 10,929 patients yielded 20.1% positive screens, 60% of whom were assessed as having probable major depression based on the PHQ-9 (11.8% of all screens) (n = 1,313). In total, 761 patients with probable major depression completed the baseline assessment. Comorbid mental illnesses (e.g., anxiety, PTSD) were highly prevalent. Medical comorbidities were substantial, including chronic lung disease, pneumonia, diabetes, heart attack, heart failure, cancer and stroke. Nearly one-third of the depressed PC patients reported recent suicidal ideation (based on the PHQ-9). Sexual dysfunction was also common (73.3%), being both longstanding (95.1% with onset >6 months) and frequently undiscussed and untreated (46.7% discussed with any health care provider in past 6 months). Practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. The substantial level of comorbid physical and mental illness among PC patients precludes solo management by either PC or mental health (MH) specialists. PC practice- and provider-level guideline adherence is problematic without systems-level solutions supporting adequate MH assessment, PC treatment and, when needed, appropriate MH referral.

Screening for Child and Adolescent Depression in Primary Care Settings: A Systematic Evidence Review for the US Preventive Services Task Force

Depression among youth is a disabling condition that is associated with serious long-term morbidities and suicide. To assess the health effects of routine primary care screening for major depressive disorder among children and adolescents aged 7 to 18 years. Medline, the Cochrane Central Registry of Controlled Trials, PsycInfo, the Cochrane Database of Systematic Reviews, recent systematic reviews, experts, and bibliographies from selected studies were the data sources. The studies selected were fair- and good-quality (on the basis of US Preventive Services Task Force criteria) controlled trials of screening and treatment (selective serotonin reuptake inhibitor and/or psychotherapy), diagnostic accuracy studies, and large observational studies that reported adverse events. Two reviewers quality-graded each article. One reviewer abstracted relevant information into standardized evidence tables, and a second reviewer checked key elements. We found no data describing health outcomes among screened and unscreened populations. Although the literature on diagnostic screening test accuracy is small and methodologically limited, it indicates that several screening instruments have performed fairly well among adolescents. The literature on treatment efficacy of selective serotonin reuptake inhibitors and/or psychotherapy is also small but includes good-quality randomized, controlled trials. Available data indicate that selective serotonin reuptake inhibitors, psychotherapy, and combined treatment are effective in increasing response rates and reducing depressive symptoms. Not all specific selective serotonin reuptake inhibitors, however, seem to be efficacious. Selective serotonin reuptake inhibitor treatment was associated with a small absolute increase in risk of suicidality (ie, suicidal ideation, preparatory acts, or attempts). No suicide deaths occurred in any of the trials. CONCLUSIONS. Limited available data suggest that primary care-feasible screening tools may accurately identify depressed adolescents and treatment can improve depression outcomes. Treating depressed youth with selective serotonin reuptake inhibitors may be associated with a small increased risk of suicidality and should only be considered if judicious clinical monitoring is possible.

Validity of the ALS-Depression-Inventory (ADI-12)— A new screening instrument for depressive disorders in patients with amyotrophic lateral sclerosis

Background Depressive symptoms among patients with amyotrophic lateral sclerosis (ALS) are usually measured with conventional questionnaires. These measurements do not consider the specific circumstances of the underlying disease. The purpose of this study was to assess the validity of a new short 12 items ALS-Depression-Inventory (ADI-12). We determined convergent, criterion, and concurrent validity. The Structured Clinical Interview (SCID) for DSM-IV was used as the gold standard and the Beck Depression Inventory (BDI) and the WHO Well Being Index (WHO-5) to assess concurrent validity. Methods A total of 39 ALS patients in all stages of the disease were interviewed. Convergent validity was estimated by the inter-correlation between the ADI-12 and the BDI. Criterion and concurrent validity were specified with respect to sensitivity, specificity and predictive values. Receiver Operating Characteristics (ROC) and Areas Under the Curves (AUC) were calculated. Results All three depression scales showed excellent internal consistencies (Cronbach's α: .8–.9). The correlation between the ADI-12 and the BDI was high ( r = .80). For the ADI-12 a cut-off of ≥ 30 (SE = 100%, SP = 83%) identified all patients with a current episode of major depression. A more liberal cut-off (≥ 23) identified all patients with any depressive disorder including minor depression at the cost of specificity (60%). Conclusions With the ADI-12 ALS patients with depressive disorders can be reliably identified. We recommend the ADI-12 for routine screening in primary care of ALS patients.

An evaluation of dementia screening in the primary care setting

To evaluate current screening methods for dementia to determine the most accurate and efficient tools for use in primary care. Search included the following: Medline, CINAHL, BIOSIS, PsycINFO, ISI Web of Science, and Health & Psychosocial Instruments (1840-2005). The following search terms were used: screen, screening, tools, Mini Mental, MMSE, clock drawing, subjective memory, assessment, diagnosis, primary care, outpatient, community based, ambulatory care, dementia, cognitive impairment, and memory impairment. There was no limit to publication year. Articles excluded were those not published in English and those which used screening tools as part of diagnostic evaluation. The search revealed 581 relevant articles, which were narrowed to 20. The Mini Mental State Examination (MMSE) has high sensitivity and specificity in outpatients older than 65 years when age- and education-specific cutoffs are used. The clock drawing test has lower sensitivity and specificity when used alone; however, in combination with the MMSE, its sensitivity is higher than that of the MMSE while specificity is slightly lower. Subjective memory complaints contribute diagnostic information; however, objective memory performance is a stronger predictor of future dementia. All measures are subject to influence by age, education, and other physical factors. The body of evidence regarding dementia screening methods has increased in recent years. The studies have been well conducted, of large sample size, in various geographic locations and populations, and by numerous investigators. Dementing illnesses will become a common presentation in primary care. Currently, routine screening is not conducted although acceptable instruments, such as the MMSE, are available. Additional research on routine screening in primary care to bolster the current evidence, use of nurses as evaluators of cognition, and utilization of specialists is needed.

Screening for Speech and Language Delay in Preschool Children: Systematic Evidence Review for the US Preventive Services Task Force

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Published in the public domain by the American Academy of Pediatrics. Speech and language development is a useful indicator of a child's overall development and cognitive ability and is related to school success. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age, when the chances for improvement are best. However, optimal methods for screening for speech and language delay have not been identified, and screening is practiced inconsistently in primary care. We sought to evaluate the strengths and limits of evidence about the effectiveness of screening and interventions for speech and language delay in preschool-aged children to determine the balance of benefits and adverse effects of routine screening in primary care for the development of guidelines by the US Preventive Services Task Force. The target population includes all children up to 5 years old without previously known conditions associated with speech and language delay, such as hearing and neurologic impairments. Studies were identified from Medline, PsycINFO, and CINAHL databases (1966 to November 19, 2004), systematic reviews, reference lists, and experts. The evidence review included only English-language, published articles that are available through libraries. Only randomized, controlled trials were considered for examining the effectiveness of interventions. Outcome measures were considered if they were obtained at any time or age after screening and/or intervention as long as the initial assessment occurred while the child was < or =5 years old. Outcomes included speech and language measures and other functional and health outcomes such as social behavior. A total of 745 full-text articles met our eligibility criteria and were reviewed. Data were extracted from each included study, summarized descriptively, and rated for quality by using criteria specific to different study designs developed by the US Preventive Services Task Force. The use of risk factors for selective screening has not been evaluated, and a list of specific risk factors to guide primary care physicians has not been developed or tested. Sixteen studies about potential risk factors for speech and language delay in children enrolled heterogeneous populations, had dissimilar inclusion and exclusion criteria, and measured different risk factors and outcomes. The most consistently reported risk factors included a family history of speech and language delay, male gender, and perinatal factors. Other risk factors reported less consistently included educational levels of the mother and father, childhood illnesses, birth order, and family size. The performance characteristics of evaluation techniques that take < or =10 minutes to administer were described in 24 studies relevant to screening. Studies that were rated good to fair quality reported wide ranges of sensitivity and specificity when compared with reference standards (sensitivity: 17-100%; specificity: 45-100%). Most of the evaluations, however, were not designed for screening purposes, the instruments measured different domains, and the study populations and settings were often outside of primary care. No "gold standard" has been developed and tested for screening, reference standards varied across studies, few studies compared the performance of > or =2 screening techniques in 1 population, and comparisons of a single screening technique across different populations are lacking. Fourteen good- and fair-quality randomized, controlled trials of interventions reported significantly improved speech and language outcomes compared with control groups. Improvement was demonstrated in several domains including articulation, phonology, expressive language, receptive language, lexical acquisition, and syntax among children in all age groups studied and across multiple therapeutic settings. Improvement in other functional outcomes such as socialization skills, self-esteem, and improved play themes were demonstrated in some, but not all, of the 4 studies that measured them. In general, studies of interventions were small and heterogeneous, may be subject to plateau effects, and reported short-term outcomes based on various instruments and measures. As a result, long-term outcomes are not known, interventions could not be compared directly, and generalizability is questionable. Use of risk factors to guide selective screening is not supported by studies. Several aspects of screening have been inadequately studied to determine optimal methods, including which instrument to use, the age at which to screen, and which interval is most useful. Trials of interventions demonstrate improvement in some outcome measures, but conclusions and generalizability are limited. Data are not available addressing other key issues including the effectiveness of screening in primary care settings, role of enhanced surveillance by primary care physicians before referral for diagnostic evaluation, non-speech and language and long-term benefits of interventions, and adverse effects of screening and interventions.