Screening increases psychological referrals for youth with abdominal pain

Last Updated: 2018-07-25

By Will Boggs MD

NEW YORK (Reuters Health) - Psychological screening integrated into medical care can significantly increase psychological referral rates for young patients with abdominal pain, researchers report.

"A brief psychological screening process can be readily integrated into medical practice and yield clinically meaningful information to providers," Dr. Natoshia R. Cunningham from Cincinnati Children's Hospital Medical Center and the University of Cincinnati in Ohio told Reuters Health by email. "Specifically, by identifying youth with abdominal pain who are at risk for the poorest outcomes (i.e., those with elevated levels of anxiety, pain, and pain-related disability), care can be personalized and patient outcomes potentially improved."

As many as 85% of youth with functional abdominal pain disorders (FAPD) also have anxiety disorders, which are associated with increased and persistent pain and disability and poorer treatment responses.

The American Academy of Pediatrics recommends psychological screening as part of routine medical care, but youth with FAPD are not systematically identified or managed in current care practices.

Dr. Cunningham's team used quality improvement methods and traditional analytic approaches to test the feasibility and outcomes of routine psychological screening in patients ages 8 to 18 years with abdominal pain.

During testing in the pilot clinic, monthly screening rates fluctuated from 0% to 97.8%. After large-scale implementation, 94% of children whose presenting complaint included abdominal pain completed all of the screening questionnaires.

A high screening rate was maintained after the formal completion of the project, according to the July 25 Pediatrics online report.

Among those screened, 43.1% had clinically significant anxiety based on their Screen for Child Anxiety Related Disorders (SCARED) scores, 45% had moderate or severe functional disability, and 61.5% had moderate pain in the past week. About a fifth (21.1%) had clinical elevations in all three screening areas.

Psychological referrals increased from an average of 8.3 per 1000 patients per month before integration of psychological screening to an average of 15.2 per 1000 patients per month after integration of psychological screening.

Just under 12% of individuals screened received referrals to psychological services, and 34% of patients with clinical elevations in all three screening areas received psychological referral.

Gastroenterology providers generally rated the process positively. They reported that screening revealed important information that would not otherwise have been known, helped frame the conversation with the patient, and offered a systematic approach to care.

"Overall, this psychological screening process has the potential to improve the quality of care for pediatric patients with functional abdominal pain disorders and may be broadly applicable to the assessment and treatment of other pediatric medical conditions," Dr. Cunningham said.

"The biggest barrier to implementation of such a program is access to resources, including access/availability of trained psychological providers to help address the issues identified through the psychological screening," she said. "To address this issue, we have developed and are currently testing a tailored psychological treatment for youth with abdominal pain and co-occurring anxiety. This approach includes web-based components, which may reduce face-to-face time needed with a psychological provider and increase access to care."

Dr. Miranda van Tilburg from University of North Carolina School of Medicine, Chapel Hill and Campbell University College of Pharmacy and Health Sciences, Buies Creek, who has investigated associations between pediatric FAPD and anxiety, told Reuters Health, "There is the misconception that all children with abdominal pain suffer from anxiety, but less than half meet screening criteria (and likely fewer get a diagnosis) or are very disabled. Many of these children are doing relatively okay. However, they still need some help with managing their pain."

"From experience I know that almost all pediatric gastroenterologists would love to work with a psychologist in their practice, but barriers prevent them from making integrative therapy a reality," she said in an email. "Showing integrative care can work and screening can be done electronically has no value unless the pediatricians can refer patients to a therapist."

Dr. van Tilburg said, "What we need is: (1) Train more psychologists and other therapists in chronic pain management. (2) Better insurance reimbursement for psychological treatment. (3) Better access to therapists."

"The paper is like selling an ideal that is not workable but for a handful of centers in the U.S.," she said. "I hope it will be used to bring about change in how we train psychologists and how we reimburse treatment. The latter is the more important piece of the puzzle that we haven't been able to solve. I hope we will start focusing on addressing these barriers."

SOURCE: http://bit.ly/2uP6A2L

Pediatrics 2018.