Jolles Mónica Pérez, Mack Wendy J, Rubio Samantha, Helmkamp Laura J, Saldana Lisa, Aarons Gregory A, Lau Anna S
Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
Implement Sci Commun. 2025 Sep 1;6(1):92. doi: 10.1186/s43058-025-00771-4.
Adverse Childhood Experiences (ACEs) screenings are increasingly being used in primary care clinics to identify toxic stress and potential trauma in children. ACEs are negative life events (e.g., violence exposure) occurring before age 18, that can increase health risks when unaddressed. However, we lack evidence on the impact of ACEs screenings and how they can be feasibly implemented in community-based clinics. We partnered with federally qualified health clinics to test the impact of a multifaceted implementation strategy on ACEs screening reach and mental health referrals for children ages 0-5.
We conducted a Hybrid Type 2 pilot trial using a stepped-wedge design (2021-2024). Reach data was measured as the proportion of eligible children screened for ACEs, with data collected from Electronic Health Records. We also assessed the percentage of mental health service referrals among all eligible children. Study clinics (n = 3) switched from no ACEs screenings (control) to implementing ACEs screenings supported by the multi-faceted ACE implementation strategy (intervention). The tested strategy comprised personnel training (e.g., trauma-informed care), integrated technology, team-based screening workflows, and ongoing care team implementation support. Additional clinics (n = 2) implemented ACEs screenings as usual without the strategy and served as additional comparison sites for exploratory analyses. Log-binomial and robust Poisson regression models examined differences in screening reach and referrals and were adjusted for site and patient race.
Screening reach rates increased in the intervention period, from 0.0% of patients screened during control to 11.2% screened during intervention. Mental health service referrals increased from 0.4% at control to 7.2% during the intervention, resulting in a risk difference (95% confidence interval) of 6.9% (6.0%, 7.7%). For both the reach and referral outcomes, risk differences were significantly greater for 18-to-60-month-old patients than for patients under 18-months-old.
Healthcare policy efforts promoting ACEs screenings in primary care are commendable. We found that a multi-faceted implementation strategy informed by partners and designed to support ACEs screenings in community-based clinics was feasible. However, its impact was attenuated by policy requirements, clinics' capacity to add ACEs screenings to strained workflows, and multiple impactful outer-context events related and unrelated to the COVID-19 pandemic.
Trial # NCT04916587 registered at clinicaltrials.gov on June 4, 2021, https://clinicaltrials.gov/study/NCT04916587.
儿童期不良经历（ACEs）筛查在基层医疗诊所中越来越多地被用于识别儿童的毒性应激和潜在创伤。ACEs是18岁之前发生的负面生活事件（如接触暴力），若不加以解决，会增加健康风险。然而，我们缺乏关于ACEs筛查的影响以及如何在社区诊所中切实可行地实施筛查的证据。我们与联邦合格健康诊所合作，测试多方面实施策略对0至5岁儿童ACEs筛查覆盖率和心理健康转诊的影响。
我们采用阶梯楔形设计（2021 - 2024年）进行了一项2型混合试点试验。筛查覆盖率数据通过接受ACEs筛查的符合条件儿童的比例来衡量，数据从电子健康记录中收集。我们还评估了所有符合条件儿童中接受心理健康服务转诊的百分比。研究诊所（n = 3）从无ACEs筛查（对照）转变为实施由多方面ACE实施策略支持的ACEs筛查（干预）。所测试的策略包括人员培训（如创伤知情护理）、集成技术、基于团队的筛查工作流程以及持续的护理团队实施支持。另外两家诊所（n = 2）照常实施ACEs筛查但没有该策略，并作为探索性分析的额外对照站点。对数二项式和稳健泊松回归模型检验了筛查覆盖率和转诊率的差异，并对站点和患者种族进行了调整。
在干预期，筛查覆盖率有所提高，从对照期筛查的患者比例0.0%增至干预期的11.2%。心理健康服务转诊率从对照期的0.4%增至干预期的7.2%，风险差异（95%置信区间）为6.9%（6.0%，7.7%）。对于筛查覆盖率和转诊结果，18至60个月大的患者的风险差异显著大于18个月以下的患者。
在基层医疗中推动ACEs筛查的医疗政策努力值得称赞。我们发现，由合作伙伴提供信息并旨在支持社区诊所进行ACEs筛查的多方面实施策略是可行的。然而，其影响因政策要求、诊所在紧张工作流程中增加ACEs筛查的能力以及与新冠疫情相关和不相关的多个有影响力的外部事件而减弱。
试验编号NCT04916587于2021年6月4日在clinicaltrials.gov注册，https://clinicaltrials.gov/study/NCT04916587 。
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