Could too much intake screening be harming care quality?

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Patient visits to Federally Qualified Health Centers (FQHCs) usually begin with numerous screening questionnaires intended to meet performance metrics. But a new study finds that this process may unintentionally be harming some aspects of patient care.

The study was designed to test the accuracy and utility in real-world settings of two tests that the authors previously had found to have high levels of repetition, the Patient Health Questionnaire (PHQ-2) and Generalized Anxiety Disorder (GAD-2) test.

They did so by comparing rates of positive tests administered in the study population to U.S. Census data and published literature. In addition, they measured the tests’ accuracy by comparing their scores to diagnoses for corresponding patients. The study population consisted of patients aged 18 or older with at least one visits to one of 24 FQHCs between 2019 and 2021.

Analysis of the results showed 11% of patients with positive scores on their first screenings for both the PHQ-2 and GAD-2 tests. By contrast, between 26% and 43% of first PHQ-2 screens were positive in the literature and census data sets, and between 47% and 53% of GAD-2 first screens were positive in the literature and census data.

Among patients with new diagnoses, the screenings detected risk in 57.7% of those with patients subsequently diagnosed with depression and 57.3% of those later diagnosed with anxiety.

The authors speculate that their findings “raise the possibility that when done frequently to meet performance thresholds, such screenings may be performed in a “perfunctory or inconsistent manner” that reduces the tests’ sensitivity to the conditions they’re screening for.

They add that “focusing on incentivized process measures like intake screening questionnaires leads to repetitive and, we hypothesize, inaccurate completion. The impact on outcomes that matter” and that “ineffective screening may unintentionally detract from clinical care because care teams and patients have less time and cognitive energy to focus on other priorities during busy clinical encounters.”

The study, “Reduced Accuracy of Intake Screening Questionnaires Tired to Quality Metrics,” appears in the September/October, 2023 issue of Annals of Family Medicine.