Transcript Reduction in waiting time in autism diagnosis by service

Reduction In Waiting Time In Autism
Diagnosis By Service Re-modelling
2006 To 2013
(Newham Locality, East London Foundation Trust)
Ben Ko, Consultant Community Paediatrician
Priti Patel, Consultant Child and Adolescent Psychiatrist
Cathie O’Driscoll, Consultant Child and Adolescent Psychiatrist (retired)
Meng Tan, Consultant Community Paediatrician
Study aim and methodology
• Aims
• Benchmark autism assessment service against national standards for
diagnostic assessments
• Evaluate if service re-design had improved waiting times for autism
diagnosis
• Methodology
• Snap shot of waiting times of three 12-month cohorts:
• Cohort 1 (2006): Baseline
• Cohort 2 (2009): Post change to assessment model for under 5s
• Cohort 3 (2012): Post change to assessment model for 5-19 year olds
• Data captured by an in-house access database implemented in 2005
• Inclusion: all cases referred for ADI-R or ADOS following initial
assessments
• Exclusion: cases that had more than one appointment prior to referral
to pathway
Autism spectrum disorders (ASD): national
guidelines on diagnostic assessment
• Stage 1: General
Developmental
Assessment (13 weeks)
• Stage 2: Multiagency
Assessment, including ASD
specific developmental
history and observations
across more than one
setting (17 weeks)
National Autism
Plan for Children
(NIASA, 2003)
• ASD specific developmental
history e.g. ADI-R
• Direct observation, consider
specific instrument e.g.
ADOS
• No timescale recommended
Assessment,
diagnosis and
clinical interventions
for children and
young people with
ASD
(SIGN, 2007)
• Developmental history
• Assessment of social and
communication skills through
interaction and observation
• Start the autism diagnostic
assessment within 3 months
of referral to the autism team
(no further timescales)
Autism:
Recognition, referral
and diagnosis of
children and young
people on the
autism spectrum
(NICE, 2011)
Diagnostic process aligned with ICD 10 and DSM 4 criteria
Newham ASD Diagnostic Service Model for under 5s
(Community Child Health Services only)
Pre-2007
Stage 1: Initial
Multidisciplinary
assessment
• Paediatrician, SLT,
OT
• General
developmental
assessment
Stage 2: Autism
specific assessment
•
•
•
•
ADI-R
ADOS
Education report
SLT report
Feedback to parents
• ASD Diagnosis
• Developmental
profile and comorbidities
From 2007
Stage 1: Initial
Multidisciplinary
assessment
• Paediatrician, SLT,
OT
• General
developmental
assessment
Stage 2: Autism
specific assessment
• ADI-R
• ADOS for complex
cases only
• Education report
• SLT report
Feedback to parents
• ASD Diagnosis
• Developmental
profile and comorbidities
Newham ASD Diagnostic Service Model for 5 to
19 year olds (CCHS & CAMHS joint service)
Pre 2011
Stage 1: Joint
Paediatric/CAMHS
assessment
• Paediatrician,
Psychiatrist or Clinical
Psychologist
• General history,
observation and
examination
Stage 2: Autism specific
assessment
•
•
•
•
ADI-R
ADOS
Education report
SLT report if indicated
Feedback to parents
• ASD Diagnosis
• Neurodevelopmental
profile and comorbidities
From 2011
Screening process prior
to referral acceptance
• Single discipline
generic assessment
(CCHS or CAMHS)
• SCQ
• School report
• SLT report if indicated
• Parental consent
Joint Paediatric/CAMHS
assessment
•
•
•
•
General observation
Physical examination
ADI-R
ADOS
Feedback to parents
• ASD Diagnosis
• Neurodevelopmental
profile and comorbidities
Added value of CAMHS input
• Broadening the focus of the assessment to incorporate a
psychological understanding of the case and the
contribution of other factors affecting the child’s
presentation
• competing and comorbid diagnoses e.g. ADHD, OCD,
social phobia and their relative contribution to the child’s
presentation
• parental mental health difficulties and its impact on the
child’s presentation e.g. Attachment disorders,
depression, substance misuse
• Being able to respond to emotional and behavioural
presentations in the child by referral to CAMHS
Comparison Table of all cohorts
Cohort
year
Age
Group
Total
number
completed
ASD
assessment
Waiting
time
range
(weeks)
Mean
(weeks)
Median
(weeks)
2006
Under 5
25
22-57
36.6
38.3
2009
Under 5
38
15-47
27.8
25.3
2012
Under 5
43
7-39
23.7
23.9
2006
5-19
5
29-53
38.2
32.0
2009
5-19
37
18-51
29.3
27.0
2012
5-19
39
0-40
11.0
11.5
Note: There has been no increase in clinician workforce or ASD clinic sessions
throughout the study period
Overall trend from 2006-2013
Waiting time from initial assessment
to ASD diagnosis (under 5s)
Waiting time from initial assessment
to ASD diagnosis (5-19)
70
70
Model changes
Model changes
60
60
Waiting time in weeks
Waiting time in weeks
50
40
50
40
30
30
20
20
10
10
0
2005
2006
2008
2009
2010
2012
2013
2014
0
2005
2006
2008
2009
2010
2012
2013
2014
Summary and conclusions: What have we learned?
• Autism assessment service delivery is an iterative
•
•
•
•
process – continuous development and refining
Value of audits to identify bottlenecks to inform change
Value of multidisciplinary model and involvement in
service development
Holistic model: tools do not replace clinical acumen
Parent and child centred
• Timing of assessment
• Involvement in diagnostic formulation
• Further development:
• MDT case discussion for complex cases
• Continuous improvement of cost effectiveness
Any questions?