A novel triage approach of child preventive health assessment: an observational study of routine registry-data

A preventive health care programme for children and young people can be found in most countries, with major attention being paid to immunisation, systematic screening for asymptomatic children and the detection of disorders [1],[2]. Structural reforms of the health care systems in many countries today and increased attention to such health problems as mental health disorders and lifestyle issues are calling for changes to the system of preventive health care for children as well [3],[4]. Preventive Youth Health Care (PYHC) services must be better aligned with current health priorities but must also address uneven access to care, inadequate programme quality and workforce shortages [5].

To meet these current health care needs of society, a novel approach has recently been developed for the provision of PYHC for children four to eighteen years in the Netherlands. This approach is based on triage and a shifting of the tasks among health care professionals. Triage can be defined as the process of determining clinical need, the likely response to intervention and the degree of urgency for such intervention [6]. The shifting of tasks can be defined as the delegation of existing tasks to current or new professionals who have less and/or more specific (i.e. tailored) training. Although triage and a shifting of the tasks of health care professionals have so far been introduced primarily in primary health care and emergency health care services, the integration of these principles in the PYHC system may have several promising advantages. These are: optimal use of the skills and expertise of health care professionals; reduced workloads of doctors and nurses; improved accessibility of health care and greater patient satisfaction [7]-[9]. To meet these current health care needs of society, a novel approach has recently been developed for the provision of PYHC for children in the Netherlands. This approach is based on triage and a shifting of the tasks among health care professionals.

The PYHC system of the Netherlands is unique. It has been offering routine preventive public health care to all Dutch children from birth to eighteen-years of age for more than a hundred years. Access is free of charge and thus independent of insurance status. The Dutch PYHC has been aimed at monitoring the growth and development of children and at prevention of children's health problems. The system has been set up for preventive and screening services for asymptomatic children, including the provision of the national vaccination programme. A standard call-up scheme is utilised for this purpose. Data of children to be invited for an assessment are provided by municipal registries (zero to three years) or by schools (four to eighteen-years). Traditionally, all children receive about seventeen routine health assessments, thirteen in the period from birth to three years (i.e. well baby clinics) and three times for the age group four to eighteen-years (i.e. school health services). These assessments consist of a general physical examination including standardised screening procedures with regard to specific health related topics, and an interview with parents or with older children themselves concerning the child's physical, developmental and psychosocial health. When problems are detected, PYHC doctors and nurses decide whether there is any need for advice, extra assessments by PYHC, or referral to specialised care. The specially trained community health care doctors, nurses and doctor's assistants (henceforth: PYHC professionals) work separately from specialised clinical caregivers such as paediatricians or other clinical health professionals. PYHC professionals keep records on the routine health assessments in a registry system. The attendance rates for routine assessment are typically very high (i.e., more than 85% on average) [10],[11]. The majority of children who are seen for such PYHC assessment show no health problems at the time. This raises the question of what frequency of routine PYHC assessment is most suitable and whether this must always be conducted by a doctor or a nurse. Some PYHC organisations in the Netherlands have introduced a triage approach to make the procedure for detecting children with health problems or at risk for health problems more efficient.

A two-step procedure has been adopted for children four to eighteen-years of age in the Netherlands. In contrast to traditional PYHC, not all children are assessed by a doctor or a nurse in this new triage approach. Rather, children are seen by a doctor's assistant who follows a strict pre-assessment protocol and refers only children with suspected health care needs for follow-up assessment by a PYHC doctor or nurse. Both pre-assessment and follow-up assessment are part of the triage health assessment procedure. This possibly creates time for PYHC doctors and nurses to devote their attention to children who need extra care, such as children with mental health and lifestyle related problems. More time in that case will be available for assessment of children on request of parents, teachers, professionals and children themselves.

For a health screening programme it is essential that it is accessible for the population of children. Further, it should been assured that children are referred to the appropriate services according to their needs [12]. In this article, we report the results of a pilot study of the accessibility of PYHC assessment and delivery of preventive care by organisations that adopted the newly developed triage approach for PYHC in the Netherlands. As can be seen from Figure 1, the triage approach with PYHC pre-assessment by a specially trained assistant introduces an earlier filter to more intensive levels of health care [13],[14]. This can possibly affect the access to PYHC assessment services by the public and delivery of PYHC care [15]-[19]. We therefore addressed the following research questions. What are the attendance (i.e. utilisation) rates for routine PYHC assessment when a triage as opposed to traditional approach is used? What are the rates of referral (i.e. delivery of care) when a triage as opposed to traditional approach is used?

The present pilot study was conducted to provide preliminary answers to these questions and is preparatory for future inquiries into the equity of service delivery and consequences for health outcomes of a triage approach to PYHC. We hypothesised the following: 1) With regard to attendance rates for routine PYHC assessment appointments, the triage and traditional approaches could be expected to produce equal results. This would indicate equal access to care. 2) With regard to the delivery of preventive care we hypothesised that triage may lead to fewer routine PYHC assessments by doctors as opposed to the traditional approach, as well as fewer indications for extra PYHC assessments and referrals to external specialised care givers.

Table 1 presents the background characteristics of the children participating in the study. The study groups did not differ significantly in terms of gender and socio-economic status, but the mean age of the children differed between the two approaches, 5.7 years for the traditional approach and 6.3 years for the triage approach.

The appointment attendance of the traditional assessment has been compared with the appointment attendance of pre-assessment and follow-up assessment of the triage approach. Our results show no significant different appointment attendance rates for the two approaches to PYHC.

As can be seen from Table 2, 351 of the sample of 390 children (90.0%) who were invited for an assessment in the traditional group, actually attended this assessment. In the triage group 372 of the sample of 386 children (96.4%) attended a pre-assessment by a doctor's assistant and 143 of the sample of 163 children (87.7%) who were referred to a follow-up assessment by the doctor or nurse indeed attended this assessment.

All of the children in the traditional group received routine PYHC assessment by a doctor while only 46% of the children in the triage group required PYHC assessment by a doctor or a nurse. Next, the percentages of children referred for extra care were compared (see Table 3). A significant difference was found: 45.9% for the traditional group were referred to extra care as compared to 19.6% for the triage group (OR = 3.9, 95% CI = 2.7-5.8).

The percentages of children referred to extra care also differed significantly for the health indicators visual disorder and overweightness between the traditional versus triage group. For possible visual impairments, 8.3% of the children in the traditional group were referred to extra care, compared to 3.2% of the children in the triage group (OR = 3.0, 95% CI = 1.5-6.1), after 9.7% had seen a PYHC doctor or nurse for follow-up assessment. For possible problems of overweightness, 12.3% of the children in the traditional group were referred to extra care, compared to 5.4% in the triage group (OR = 3.6, 95% CI = 1.9-6.7), after 8.1% had seen a PYHC doctor or nurse for follow-up assessment. No difference was found for the health indicator psychosocial problems. For suspected psychosocial problems, 8.0% of the children in the traditional group were referred for extra PYHC or external care compared to 5.1% of the children in the triage group (OR = 1.1, 95% CI = 0.7-3.0), after 15.9% in this group had seen a PYHC doctor or nurse for follow-up assessment.

The two approaches also differed in terms of the proportions of children who were referred to extra care by PYHC and those who were referred to specialised care outside of PYHC. In the traditional approach 39.9% of 351 children were referred to extra care by PYHC, versus 14.8% of 372 children who received triage approach (OR = 4.5, 95% CI = 3.0-6.7). 12.5% of 351 children in the traditional approach versus 5.1% of 372 children in the triage approach were referred to specialised care (OR = 2.4, 95% CI = 1.3-4.7).

In this study, a novel method of triage for the public health assessment of children combined with a shifting of the tasks of Preventive Youth Health Care (PYHC) professionals was explored. We compared the attendance rates for the PYHC assessment appointments in groups using a triage approach versus a traditional approach. PYHC appointment attendance rates were taken to be indicators of the accessibility of PYHC. We also examined the referral rates for extra PYHC assessment or external specialised care, called `extra care', as indicators of delivery of preventive care, assuming that referral is a vital part of the care delivered by PYHC.

The type of approach, i.e. a triage or traditional approach did not affect the accessibility of the routine PYHC assessment. The appointment attendance rates for PYHC assessment, which are traditionally quite high, continued to be high also for the triage approach to assessment. The attendance rate of the pre-assessment appointments were probably high because the parents were not required to be present.

Major differences in the referral rates for extra care were detected when the traditional approach was compared to the triage approach: lower referral rates for extra care were found for the triage approach relative to the traditional approach. The different referral rates for extra care can most likely be attributed to the different processes used to identify health problems in the two approaches. In the traditional assessment approach, all children are assessed by a PYHC doctor or nurse. In the two-step, triage approach to assessment, all children are pre-assessed by a doctor's assistant and only those in need of follow-up (i.e. with health problems or at risk for health problems) are referred for assessment by a PYHC doctor or nurse. It is possible that this two-step approach provides an additional barrier to access to care. Children with health problems may be under-identified (false negatives, i.e. incorrectly classified as healthy) and therefore not referred for extra care. Another explanation for the lower referral rates is that in the second step in the triage assessment process, the PYHC doctor or nurse can provide more tailored advice, recommendations and reassurance, which can remove the need for further referral to extra care. It is, of course, also possible that spontaneous remission occurs during the period between pre-assessment by the doctor's assistant and follow-up by the PYHC doctor or nurse and that this reduces referral for extra care in the triage group in particular. We did not measure the care which may have been sought during the period between pre-assessment and follow-up assessment, although this could also account for the significantly lower rate of referral for extra care in the triage group compared to the traditional group. Finally, the different referral rates found for extra care in the two groups might lie in earlier identification of health problems in the triage group as the triage approach to assessment allows for more responding to requests and questions from parents, teachers and the children themselves and may therefore nip more problems in the bud than a traditional approach to assessment.

When we compared the referral rates for extra care for psycho social problems, visual disorders and overweightness in our study to the actual prevalence rates for these problems among five and six year olds in the Netherlands, the triage referral rates resembled the actual prevalence rates of six percent for psychosocial problems and two to four percent for visual disorders [8],[25]. The traditional-group referral rate of twelve percent for extra care for overweightness was higher than the triage group referral rate of five percent, but approached the actual prevalence rate of fifteen percent among five and six-year olds in the Netherlands [26],[27]. The referral rates for both the triage and the traditional groups in the present study represent health problems which have been newly identified by the PYHC service while the actual prevalence rates include problems which are already known. This means that PYHC referral rates for extra care may be lower than prevalence rates. More detailed and large-scale research on PYHC assessment practices and approaches is needed to gain insight in the identification of care needs and subsequent referrals.

The present results show that a triage approach compared to routine PYHC assessment maintains the accessibility of assessments. The use of doctors and nurses for routine assessments has been reduced through a shift of assessment tasks among the PYHC professionals. The delivery of preventive care to children, including referral to external services has changed in the new approach. The triage approach for PYHC assessment may create opportunities for greater attention from doctors and nurses to children who are at risk and to children with clear health needs. The triage approach for routine PYHC assessment and its contribution to efforts in reducing the need for specialised health care among children and into adulthood needs further validation.

JB had the original idea, contributed to the development of the triage protocols, acquisition and interpretation of data and drafting of this manuscript. MT contributed to the conception and design, analysis and interpretation of data. She was involved in revising the manuscript. PK contributed to the conception and design, analysis and interpretation of data and drafting of the manuscript. He supervised the execution of the study. SB contributed to the revision of the intellectual content of this paper. Finally, all authors read and approved the final manuscript.