A Novel Approach to Increasing Access to Developmental-Behavioral Pediatrics Subspecialty Care

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It is established that long wait times to access pediatrics subspecialty care is a weakness of the United States health care system. In 2006, the federal Maternal and Child Health Bureau and the American Academy of Pediatrics supported the preparation of a report that described pediatrics subspecialty capacity problems and difficulties accessing care.1 The benefits of access to subspecialty care have been studied, for example, in adult cardiology and gastroenterology, where subspecialist involvement is associated with improved mortality, morbidity, and improved quality of care.2–6 The benefits of access to subspecialty care also may include more complete consideration of the diagnostic differential and quicker start of treatments.
A model of access described by Penchansky and Thomas,7 modified recently by Suarman,8 and applied to health care services, highlights availability, accessibility, accommodations, affordability, acceptability, and awareness. Several of these dimensions are particularly relevant to developmental-behavioral pediatrics (DBP) health care. In the realm of availability, there are too few DBP clinicians, and those clinicians tend to be found in geographic clusters near tertiary care centers. With increased prevalence of autism and other neurodevelopmental disorders and improved survival of children who receive neonatal intensive care, there is high demand for DBP subspecialty care. Regarding affordability, inadequate insurance program coverage may create financial barriers. In terms of accessibility, there may be physical accessibility problems (e.g., entry ramps, usable restrooms) or limited options for care coordination. Finally, regarding acceptability, perceptions of stigma related to DBP conditions also can affect length of time to receive DBP subspecialty care.
In all these areas, the goal of efforts to improve access is to connect patients and their families with the DBP subspecialty medical care that they need. A recent study of limited patient access to GI subspecialty clinics considered intervention strategies at 2 levels: systems strategies and local strategies.5 At the systems level, possible strategies include expanding roles for primary care providers to manage certain conditions often seen by subspecialists, training more subspecialists, and involving general pediatricians and nurse practitioners in subspecialty clinics. Innovative coordination and communication interventions, such as e-consults and other telehealth initiatives, are alternative routes for patients with chronic conditions to access subspecialty care. Local strategies focus on the adjustment of health care delivery scheduling systems to improve access by decreasing the back log of patients, balancing supply and demand, and developing contingency plans for unusual demands.
In this issue of JDBP, the article by Harrison et al.9 addresses long wait times to access DBP subspecialists. Harrison and colleagues use a system strategy: the study evaluates an effort to embed general pediatricians within a subspecialty DBP clinic and, with this action, reduce wait time for patients to be seen. The general pediatrician was trained to address a narrow age range (<5 yr) and the diagnostic question (is ASD or developmental delay an appropriate diagnosis?). Evaluations were informed by the use of parent-reported information, i.e., a development screener (Ages and Stages Questionnaire), and a diagnosis-specific screener and scale (Modified Checklist for Autism in Toddlers and Autism Spectrum Rating Scale) plus a diagnosis-specific clinician scale (Childhood Autism Rating Scale). The process/quality improvement intervention resulted in significantly decreased wait time to initial evaluation of referred children. Secondary outcomes included the referral of a majority of patients (71%) to ancillary therapies and the movement of a significant number of patients (21/63 = 33%) off of the DBP subspecialty clinic schedule.
The strengths of this study include the use of a quality improvement approach based on previous studies at the same institution that evaluated the use of a “generalist as specialist” access model.
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