89 - Perceived Barriers to Primary Care Evaluation of Young Children with High Concern for Autism: A Multisite Study

Publication Number: 1081.89

Sarah Canale, Boston University School of Medicine, Winchester, MA, United States; Bridget Poznanski, Boston University School of Medicine, Boston, MA, United States; Marilyn Augustyn, Boston University School of Medicine, SOmerville, MA, United States; Julie O. Bickel, Boston Children's Hospital, Ashland, MA, United States; Holly Harris, Baylor College of Medicine, Houston, TX, United States; Nikki Gambhir, Baylor College of Medicine, HOuston, TX, United States; Gabriela V. Miller, Boston Children's Hospital, Brookline, MA, United States; Carol Weitzman, Boston Children's Hospital, Boston, MA, United States

Background: Increasing primary care clinician (PCC) capacity to diagnose Autism Spectrum Disorder (ASD) can reduce time to diagnosis and improve intervention access. Training studies show gains in PCC’s diagnostic competence and knowledge, yet research detailing perceived barriers to completing ASD evaluations in primary care is limited.

Objective: To describe perceived barriers to ASD evaluation by PCCs and identify PCC and practice-level associations.

Design/Methods: PCCs participating in an ASD evaluation training (8-session, 12-hour hybrid, over 8 months) within a multisite trial completed baseline surveys assessing PCC and practice characteristics and 14 barriers to ASD evaluation. PCCs rated barriers on a 4-point Likert scale and noted if the barrier would prevent an evaluation. Descriptive and multilevel models examined associations between perceived barriers and PCC/practice characteristics.

Results: PCC and practice characteristics (Table 1) and reported barriers (Table 2) are below. Practice size, location, and accepted insurance significantly differed across sites. The mean number of barriers reported by PCCs was 4.74 (SD=4.82), with one site reporting higher ratings
(F=9.96, p < 0.0001.) Time to complete evaluations, skill, and complexity of presentation were the most commonly reported barriers. On average, PCCs rated 73% of endorsed barriers as likely to prevent completing an ASD evaluation. Several barrier ratings significantly differed by sites.

Multilevel models revealed that PCCs working in practices located in mixed urban/suburban areas reported significantly more barriers than urban practices (3.95 vs 2.19; b=2.45, p<.05), higher mean barrier ratings (2.71 vs 1.84; b=0.84, p=.01) and were more likely to report that barriers may prevent evaluations (1.59 vs 0.90; b=0.54, p=.01). PCCs in practices serving uninsured patients had significantly higher mean barrier ratings (2.52 vs 1.84; b= 0.59, p<.05). There were no associations with PCC characteristics.

Conclusion(s): Site, practice location, and insurance coverage were key determinants of perceived barriers. Mixed urban/rural practices and those serving uninsured patients report greater burden and impact of barriers. PCCs indicated that many perceived barriers may prevent them from being able to complete ASD evaluations. There was considerable variability across sites, which may reflect geographic, policy, and contextual variations. Findings illustrate the importance of assessing local and systemic barriers before training to ensure effective adoption of ASD evaluation in primary care.

Table 1: Descriptive Statistics
PAS 2026 Barriers Table 1.pdfNote: Site differences tested using Chi-square. Significant result indicates significant differences between sites.
a Participants could select all that apply, so percentages are not expected to add up to 100
* indicates p<0.05; ** indicates p <0.01; ***indicates p<0.001


Table 2. Reported Barriers Ratings
PAS 2026 Barriers Table 2.pdfNote: One-way ANOVA examined site differences. Tukey’s post-hoc tests indicated the following patterns of significant differences:
Site 1 < Site 2, Site 3: Time, Patient No-Shows
Site 1 < Site 2: Support from Practice, Scheduling
Site 2 < Site 3: Adequate Number of Children
Site 1 < Site 3: Availability of Testing Materials, Adequate Payment, Parent Consent/Preference
Site 3 > Site 1, Site 2: Mean number of barriers endorsed
* indicates p<0.05; ** indicates p <0.01; ***indicates p<0.001; **** indicates p<0.0001