Reducing Unnecessary Imaging and Pathology Tests: A Systematic Review.

CONTEXT: Unnecessary imaging and pathology procedures represent low-value care and can harm children and the health care system. OBJECTIVE: To perform a systematic review of interventions designed to reduce unnecessary pediatric imaging and pathology testing. DATA SOURCES: We searched Medline, Embase, Cinahl, PubMed, Cochrane Library, and gray literature. STUDY SELECTION: Studies we included were: reports of interventions to reduce unnecessary imaging and pathology testing in pediatric populations; from developed countries; written in the English language; and published between January 1, 1996, and April 29, 2017. DATA EXTRACTION: Two researchers independently extracted data and assessed study quality using a Cochrane group risk of bias tool. Level of evidence was graded using the Oxford Centre for Evidence-Based Medicine grading system. RESULTS: We found 64 articles including 44 before-after, 14 interrupted time series, and 1 randomized controlled trial. More effective interventions were (1) multifaceted, with 3 components (mean relative reduction = 45.0%; SD = 28.3%) as opposed to 2 components (32.0% [30.3%]); or 1 component (28.6%, [34.9%]); (2) targeted toward families and clinicians compared with clinicians only (61.9% [34.3%] vs 30.0% [32.0%], respectively); and (3) targeted toward imaging (41.8% [38.4%]) or pathology testing only (48.8% [20.9%]), compared with both simultaneously (21.6% [29.2%]). LIMITATIONS: The studies we included were limited to the English language. CONCLUSIONS: Promising interventions include audit and feedback, system-based changes, and education. Future researchers should move beyond before-after designs to rigorously evaluate interventions. A relatively novel approach will be to include both clinicians and the families they manage in such interventions.

Relationship Between Executive Functioning and Symptoms of Attention-Deficit/Hyperactivity Disorder and Autism Spectrum Disorder in 6-8 Year Old Children.

This study examined relationships between executive functioning (EF) and ADHD/ASD symptoms in 339 6-8 year-old children to characterise EF profiles associated with ADHD and ADHD + ASD. ADHD status was assessed using screening surveys and diagnostic interviews. ASD symptoms were measured using the Social Communication Questionnaire, and children completed assessments of EF. We found the EF profile of children with ADHD + ASD did not differ from ADHD-alone and that lower-order cognitive skills contributed significantly to EF. Dimensionally, ASD and inattention symptoms were differentially associated with EF, whereas hyperactivity symptoms were unrelated to EF. Differences between categorical and dimensional findings suggest it is important to use both diagnostic and symptom based approaches in clinical settings when assessing these children's functional abilities.