Abstract
Background: Adverse Childhood Experiences (ACEs) have been associated with poorer long-term patient health outcomes. However, screening and intervention methods vary widely, and patient face significant challenges related to access to effective treatment options. The present quality improvement study examined trauma screening processes and intervention practices across three pediatric integrated primary care (IPC) clinics and their impact on patient outcomes.
Approach: A systematic medical record review was conducted for patients aged 5-17 who completed a well-child encounter (WCE) between October 2022 to June 2023 in three IPC clinics within a large academic medical center in the Midwestern United States. Physician use of ACEs-related questionnaires, trauma-related diagnoses, and behavioral health referrals associated with WCEs were collected. Chi-square tests were analyzed for variability.
Results: Patients (n = 4611) had a mean age of 10.8 years, were majority male (52.6%) and English-speaking (95.6%). Patient race, ethnicity, and preferred language varied significantly across clinics (p < .01). Measures assessing ACEs were completed in 51.1% of WCEs. Physicians placed a behavioral health referral at 13.5% of encounters that used an ACEs screener compared to 11.8% of encounters that did not use a screener. Trauma-related disorder diagnoses were made in 1.8% of WCEs and were associated with 6.3% of behavioral health referrals. Rates of screener completion, behavioral health referral, and trauma-related diagnosis were found to significantly vary (p < .01) based on demographic factors (e.g., age, race, clinic location, and preferred language).
Implications: Significant variability in screening practices was evident across clinics despite them existing within the same health system. The absence of systematic implementation practices results in inadequate and inequitable identification of patients with trauma exposure and critical mental health needs. Clearer guidelines and standardized practices are crucial to effectively and equitably identify and support patients with ACEs. An integrated primary care approach enables collaboration among physical health providers, mental/behavioral health professionals, community resource agencies, and patient families and is essential to manage the high volume of trauma concerns identified in the primary care sector. Currently, we are engaging primary care providers and patient families to improve the efficiency, acceptability, and sustainability of screening practices and to more effectively connect families to needed interventions and resources. Future research will examine patient follow-through with behavioral health referrals and long-term health outcomes.