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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 25 of 31 Research Studies DisplayedHickey EJ, Feinberg E, Kuhn J
Family impact during the time between autism screening and definitive diagnosis.
The purpose of this study was to explore parental perceptions of the impact their child’s behavior had on their family between the time risk of Autism Spectrum Disorder (ASD) was identified and before formal medical diagnosis, and then compare family impact among those whose child met diagnostic criteria for ASD and those who did not. The study found that the parents of children who received a non-ASD diagnosis reported a higher baseline level of family impact. Perception of difficult child behavior was a stronger predictor of family impact than later diagnostic group, and child functioning did not predict family impact. The researchers concluded that in this specific population, perceived difficult child behavior is a stronger predictor of family impact than later diagnostic category.
AHRQ-funded; HS022242.
Citation: Hickey EJ, Feinberg E, Kuhn J .
Family impact during the time between autism screening and definitive diagnosis.
J Autism Dev Disord 2022 Nov;52(11):4908-20. doi: 10.1007/s10803-021-05354-5..
Keywords: Autism, Screening, Diagnostic Safety and Quality
Bhakta BB, Coleman KJ, Choi KR
Randomized study of survey recruitment strategies for parents of autistic children.
The purpose of this study was to compare different methods of recruiting parents of autistic children to participate in an online survey. To establish a baseline, the researchers simultaneously sent an initial mailed letter and email to a sample of 1,624 parents of autistic children spectrum disorder (autism) from an integrated health system in Southern California. Participants were then randomly assigned to one of three follow-up recruitment groups: text message, email, or phone. The study found that all three of the follow-up methods were equally effective for eliciting a survey response, and that the parents of girls were less likely to respond than the parents of boys. The study concluded that text messages, email messages and phone calls are effective in recruiting parents for surveys.
AHRQ-funded; HS026407.
Citation: Bhakta BB, Coleman KJ, Choi KR .
Randomized study of survey recruitment strategies for parents of autistic children.
J Pediatr Health Care 2022 Sep-Oct;36(5):470-73. doi: 10.1016/j.pedhc.2022.05.008..
Keywords: Children/Adolescents, Autism
Lindly OJ, Cabral J, Mohammed R
AHRQ Author: Mistry KB
"I don't do much without researching things myself": a mixed methods study exploring the role of parent health literacy in autism services use for young children.
This mixed-methods study examined how parent health literacy contributes to health-related outcomes for children with autism. This study included 82 US parents of a child with autism 2-5 years old and sought to describe (1) health literacy dimensions, (2) how health literacy influences services use, and (3) health literacy improvement strategies. The authors found that: autism information was accessed from multiple sources; understanding autism information involved "doing your own research"; autism information empowered decision-making; health literacy facilitated behavioral services use; health literacy influenced medication use; family and system characteristics also affected services use; autism education remains needed; services information is needed across the diagnostic odyssey; and greater scientific information accessibility would increase uptake.
AHRQ-authored; AHRQ-funded; HS000063.
Citation: Lindly OJ, Cabral J, Mohammed R .
"I don't do much without researching things myself": a mixed methods study exploring the role of parent health literacy in autism services use for young children.
J Autism Dev Disord 2022 Aug;52(8):3598-611. doi: 10.1007/s10803-021-05240-0..
Keywords: Children/Adolescents, Autism, Caregiving, Health Literacy
Lindly OJ, Shui AM, Stotts NM
Caregiver strain among North American parents of children from the Autism Treatment Network Registry Call-Back Study.
This study showed on average caregiver strain did not significantly change in North American parents of children with autism during a 2-year period. Improved caregiver strain was found to be linked to improved child functioning and behavior. Recommendations included routine assessment of caregiver strain, and referral to evidence-based programming and supports in order to help alleviate some of the burden that families of children with autism commonly experience.
AHRQ-funded; HS000063.
Citation: Lindly OJ, Shui AM, Stotts NM .
Caregiver strain among North American parents of children from the Autism Treatment Network Registry Call-Back Study.
Autism 2022 Aug;26(6):1460-76. doi: 10.1177/13623613211052108..
Keywords: Autism, Caregiving, Children/Adolescents
Choi KR, Lotfizadah AD, Bhakta B
Concordance between patient-centered and adaptive behavior outcome measures after applied behavior analysis for autism.
In clinical trials, applied behavioral analysis (ABA) is an evidence-based approach to autism spectrum disorder that has been shown to improve child functional status. Setting and tracking individualized, patient-centered goals is a focus in ABA, yet there is little research on measuring progress on such goals. The purpose of this study was to observe and evaluate a clinical sample of children 3 to 16 years of age (N=154) receiving 24 months of ABA for autism spectrum disorder, and assess the concordance between patient-centered and standard outcome measures of treatment progress. The study found that there was limited concordance among measures at 12 and 24 months of ABA. The study also found that between 12 and 24 months of ABA, the percentage of children who achieved clinically meaningful gain on patient-centered goal measures increased, while the percentage of children who achieved clinically meaningful gains in adaptive behavior decreased. The study concluded that providers should have continuous dialogue with patients and caregivers to ensure that ASD programs and interventions progress toward meaningful goals and outcomes for patients and their caregivers.
AHRQ-funded; HS026407.
Citation: Choi KR, Lotfizadah AD, Bhakta B .
Concordance between patient-centered and adaptive behavior outcome measures after applied behavior analysis for autism.
BMC Pediatr 2022 May 27;22(1):314. doi: 10.1186/s12887-022-03383-2..
Keywords: Patient-Centered Healthcare, Autism, Behavioral Health
McBain RK, Cantor JH, Kofner A
Brief report: Medicaid expansion and growth in the workforce for autism spectrum disorder.
This study examined the role that state Medicaid expansion has played in utilization of child psychiatrists, board-certified behavioral analysts (BCBAs) and pediatricians for children with autism spectrum disorder (ASD). Health workforce data from HRSA was used to examine workforce growth from 2008-2017. State Medicaid expansion was associated with a 9% increase in BCBAs per 100,000 children one year after enactment, and a 5% increase in child psychiatrists, but no association with growth in pediatrician utilization.
AHRQ-funded; HS025750.
Citation: McBain RK, Cantor JH, Kofner A .
Brief report: Medicaid expansion and growth in the workforce for autism spectrum disorder.
J Autism Dev Disord 2022 Apr;52(4):1881-89. doi: 10.1007/s10803-021-05044-2..
Keywords: Children/Adolescents, Autism, Medicaid, Workforce, Behavioral Health
Choi K, Becerra-Culqui T, Bhakta B
Parent intentions to vaccinate children with autism spectrum disorder against COVID-19.
This study’s purpose was to investigate associations between parent vaccine confidence and intentions to have their child with autism vaccinated with the COVID-19 vaccine. A cross-sectional, web-based survey of 332 parents of children with autism spectrum disorder who were members of an integrated healthcare system in Southern California was conducted from May to July 2021. Approximately 35% of parents were going to vaccinate their child against COVID-19. Positive vaccine beliefs, healthcare provider trust, or parent vaccination status were associated with intention to vaccinate.
AHRQ-funded; HS026407.
Citation: Choi K, Becerra-Culqui T, Bhakta B .
Parent intentions to vaccinate children with autism spectrum disorder against COVID-19.
J Pediatr Nurs 2022 Mar-Apr;63:108-10. doi: 10.1016/j.pedn.2021.11.019..
Keywords: Children/Adolescents, COVID-19, Vaccination, Autism, Chronic Conditions
Choi KR, Bhakta B, Knight EA
Patient outcomes after applied behavior analysis for autism spectrum disorder.
The purpose of this study was to examine patterns of service receipt and patient outcomes for children receiving applied behavior analysis (ABA) for autism spectrum disorder (ASD) in an integrated health care system in which commercially insured children were covered by a state autism mandate. Findings showed that, in a health system implementation of ABA for children with ASD, there were high rates of ABA discontinuation and low ABA dosing. These challenges may diminish the potential benefits of ABA, even with mandated commercial insurance coverage.
AHRQ-funded; HS026407.
Citation: Choi KR, Bhakta B, Knight EA .
Patient outcomes after applied behavior analysis for autism spectrum disorder.
J Dev Behav Pediatr 2022 Jan;43(1):9-16. doi: 10.1097/dbp.0000000000000995..
Keywords: Children/Adolescents, Autism, Behavioral Health, Outcomes, Patient-Centered Outcomes Research, Evidence-Based Practice
Kuhn J, Levinson Udhnani, MD
What happens after a positive primary care autism screen among historically underserved families? Predictors of evaluation and autism diagnosis.
This study examined predictors of receiving a recommended diagnostic evaluation after a recommended primary care-administered autism screen, and of those who screen positive, who is most likely to be diagnosed with autism. Participants were 309 predominantly low-income, racial/ethnic minority parents and their child aged 15-27 months who screened positive with the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F). Significant predictors of diagnostic evaluation included older parental age, being non-Hispanic and the child having private insurance, lower child communication functioning, or receiving Early Intervention services. Significant predictors of an autism diagnosis included being male, having lower child communication functioning, screening directly in the parent’s preferred language, White/non-Hispanic parent, and no parent history of mood disorder.
AHRQ-funded; HS022242.
Citation: Kuhn J, Levinson Udhnani, MD .
What happens after a positive primary care autism screen among historically underserved families? Predictors of evaluation and autism diagnosis.
J Dev Behav Pediatr 2021 Sep;42(7):515-23. doi: 10.1097/dbp.0000000000000928..
Keywords: Children/Adolescents, Autism, Screening, Vulnerable Populations, Diagnostic Safety and Quality
Zuvekas SH, Grosse SD, Lavelle TA
AHRQ Author: Zuvekas SH
Healthcare costs of pediatric autism spectrum disorder in the United States, 2003-2015.
Published healthcare cost estimates for children with autism spectrum disorder (ASD) vary widely. One possible contributor is different methods of case ascertainment. In this study, autism spectrum disorder (ASD) case status was determined using two sources of parent reports among 45,944 children ages 3-17 years in the Medical Expenditure Panel Survey (MEPS) linked to the National Health Interview Survey (NHIS) Sample Child Core questionnaire. In this paper, the investigators describe their process and conclusions.
AHRQ-authored.
Citation: Zuvekas SH, Grosse SD, Lavelle TA .
Healthcare costs of pediatric autism spectrum disorder in the United States, 2003-2015.
J Autism Dev Disord 2021 Aug;51(8):2950-58. doi: 10.1007/s10803-020-04704-z..
Keywords: Medical Expenditure Panel Survey (MEPS), Children/Adolescents, Autism, Healthcare Costs, Behavioral Health
Hickey EJ, Stransky M, Kuhn J
Parent stress and coping trajectories in Hispanic and non-Hispanic families of children at risk of autism spectrum disorder.
This study examined trajectories of parenting stress, coping, and perceived family impact over time throughout the autism diagnostic process among Hispanic and non-Hispanic families. Findings showed that Hispanic families reported lower levels of parenting stress, coping, and negative family impact across time. Further, there were differences in the change in use of coping and the amount of negative family impact reported between Hispanic and non-Hispanic parents over time.
AHRQ-funded; HS022242.
Citation: Hickey EJ, Stransky M, Kuhn J .
Parent stress and coping trajectories in Hispanic and non-Hispanic families of children at risk of autism spectrum disorder.
Autism 2021 Aug;25(6):1694-708. doi: 10.1177/13623613211001611..
Keywords: Children/Adolescents, Autism, Stress, Behavioral Health, Racial and Ethnic Minorities
Cook A, Quinn ED, Rowland C
Exploring expressive communication skills in a cross-sectional sample of individuals with a dual diagnosis of autism spectrum disorder and down syndrome.
The authors hypothesized that individuals with a comorbid diagnosis of Down syndrome (DS) and autism spectrum disorder would have significantly lower Communication Matrix scores and specifically social communication scores than individuals with DS alone. They found that, in a sample of 4,782 individuals with DS, scores for individuals with a comorbid diagnosis were on average 18.01 points and 7.26 points lower for total score and social score, respectively, as compared to individuals with DS alone.
AHRQ-funded; K12 HS026370; 1013200.
Citation: Cook A, Quinn ED, Rowland C .
Exploring expressive communication skills in a cross-sectional sample of individuals with a dual diagnosis of autism spectrum disorder and down syndrome.
Am J Intellect Dev Disabil 2021 Mar 1;126(2):97-113. doi: 10.1352/1944-7558-126.2.97..
Keywords: Autism, Communication, Diagnostic Safety and Quality
Feinberg E, Kuhn J, Eilenberg JS
Improving family navigation for children with autism: a comparison of two pilot randomized controlled trials.
This study looked at impacts of a modification to a pilot program called Family Navigation to help low-income, minority children needing autism-related diagnostic services receive those services. An advisory group recommended modifications to recruitment criteria and study conditions. 40 parent-child dyad participants were randomized between the two pilots to receive usual care (UC) or modified FN. Participant enrollment, satisfaction with clinical care, and timely completion of the diagnostic assessment were compared. Recruitment improved significantly with the modified protocol (4.8% vs. 19.5%) and no participants were excluded from study enrollment compared to the first pilot (43.6%). Families in the second pilot were more likely to complete diagnostic assessment and report greater satisfaction with clinical care.
AHRQ-funded; HS022155; HS022242.
Citation: Feinberg E, Kuhn J, Eilenberg JS .
Improving family navigation for children with autism: a comparison of two pilot randomized controlled trials.
Acad Pediatr 2021 Mar;21(2):265-71. doi: 10.1016/j.acap.2020.04.007..
Keywords: Children/Adolescents, Autism, Patient-Centered Healthcare, Care Coordination, Racial and Ethnic Minorities, Low-Income, Patient and Family Engagement, Chronic Conditions
Grosse SD, Ji X, Zuvekas
AHRQ Author: Zuvekas SH
Spending on young children with autism spectrum disorder in employer-sponsored plans, 2011-2017.
This study looked at spending trends on young children with autism spectrum disorder (ASD) in employer-sponsored plans from 2011 to 2017. This cross-section analysis examined claims data from large-employer-sponsored health plans and assessed changes in annual expenditures by service type for children ages 3-5 enrolled for 1 year or more, and with two or more claims with ASD billing codes within a calendar year and compared it to all children. Mean spending per children with ASD increased by 51% in 2017 US dollars in 2017, while for all children the increase was 8%. ASD spending accounted for 41% of spending growth for children ages 3-7 during 2011-2017. Outpatient behavioral intervention-related spending increased by 376% during the time period, while spending on all other services increased by 2%.
AHRQ-authored.
Citation: Grosse SD, Ji X, Zuvekas .
Spending on young children with autism spectrum disorder in employer-sponsored plans, 2011-2017.
Psychiatr Serv 2021 Jan;72(1):16-22. doi: 10.1176/appi.ps.202000099.
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Keywords: Children/Adolescents, Autism, Health Insurance, Healthcare Costs
Downs SM, Bauer NS, Saha C
Effect of a computer-based decision support intervention on autism spectrum disorder screening in pediatric primary care clinics: a cluster randomized clinical trial.
This study examined outcomes for implementation of a decision support system called CHICA (Child Health Improvement Through Computer Automation) to improve screening rates for autism in children aged 18 to 24 months. A random sample of 274 children in four urban clinics was used. Two clinics participated in the intervention, and two served as controls. Because participating clinics requested intervention be discontinued for children aged 18 months, only results for those aged 24 months was analyzed. Of the 263 children with reviewed results, 92% were enrolled in Medicaid, 52.5% were African American, and 36.5% were Hispanic. Screening rates increased from 0% at baseline to 100% in 24 months during the study period of November 2010 to November 2012. Screening results were positive for 265 of 980 children screened by CHICA in the time period, with 2 children from the intervention group positively diagnosed in the time frame of the study.
AHRQ-funded; HS018453.
Citation: Downs SM, Bauer NS, Saha C .
Effect of a computer-based decision support intervention on autism spectrum disorder screening in pediatric primary care clinics: a cluster randomized clinical trial.
JAMA Netw Open 2019 Dec 2;2(12):e1917676. doi: 10.1001/jamanetworkopen.2019.17676..
Keywords: Autism, Clinical Decision Support (CDS), Shared Decision Making, Health Information Technology (HIT), Primary Care, Children/Adolescents, Screening
Lindly OJ, Zuckerman KE, Kuhlthau KA
Healthcare access and services use among US children with autism spectrum disorder.
This study’s goal was to examine healthcare access and service use among US children with autism spectrum disorder. Data was analyzed from the 2011-2014 National Health Interview Survey data on 651 children with autism spectrum disorder aged 2-17 years. Three measures of healthcare access problems were used: delays accessing healthcare, difficulty affording healthcare, and trouble finding a healthcare provider. Five service measures were used: 4 office visits, 1 well-child visit, flu vaccine, prescription medication, and 1 emergency department visit. Twenty-nine percent of children were found to have had 1 healthcare access problem. This healthcare access problem was associated with lower adjusted odds of 1 well-child visit or prescription medications but higher adjusted odds for 1 emergency department visit or 4 office visits. The association between healthcare access problems and emergency department use were higher for those with higher economic status and White, non-Hispanic subgroups.
AHRQ-funded; HS000063.
Citation: Lindly OJ, Zuckerman KE, Kuhlthau KA .
Healthcare access and services use among US children with autism spectrum disorder.
Autism 2019 Aug;23(6):1419-30. doi: 10.1177/1362361318815237..
Keywords: Children/Adolescents, Autism, Access to Care, Chronic Conditions, Disparities
Knutsen J, Crossman M, Perrin J
Sex differences in restricted repetitive behaviors and interests in children with autism spectrum disorder: an Autism Treatment Network study.
Researchers examined sex differences in clinically identified (Autism Diagnostic Observation Schedule) restricted and repetitive behavior symptoms of age-matched and intelligence quotient-matched female and male children with autism spectrum disorder. Their findings identified key restricted and repetitive behavior similarities and differences among young females and males with autism spectrum disorder and emphasized the need for a deeper understanding of the female autism phenotype.
AHRQ-funded; HS022986; HS000063.
Citation: Knutsen J, Crossman M, Perrin J .
Sex differences in restricted repetitive behaviors and interests in children with autism spectrum disorder: an Autism Treatment Network study.
Autism 2019 May;23(4):858-68. doi: 10.1177/1362361318786490..
Keywords: Autism, Behavioral Health, Children/Adolescents, Patient-Centered Outcomes Research, Sex Factors
Duvall SW, Lindly O, Zuckerman K
Ethical implications for providers regarding cannabis use in children with autism spectrum disorders.
In this paper, the authors present commentary on the ethical implications of cannabis use in children with autism spectrum disorder and severe self-harm behaviors. They discuss ethical analysis that includes harm reduction, health concerns, and information sharing.
AHRQ-funded; HS000063.
Citation: Duvall SW, Lindly O, Zuckerman K .
Ethical implications for providers regarding cannabis use in children with autism spectrum disorders.
Pediatrics 2019 Feb;143(2). doi: 10.1542/peds.2018-0558..
Keywords: Autism, Children/Adolescents, Complementary and Alternative Medicine, Neurological Disorders
Fogler J, Kuhn J, Prock L
Diagnostic uncertainty in a complex young man: autism versus psychosis.
This paper provides a case study of boy, diagnosed with attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) who was born in Vietnam to a mother with mental illness.
AHRQ-funded; HS022242.
Citation: Fogler J, Kuhn J, Prock L .
Diagnostic uncertainty in a complex young man: autism versus psychosis.
J Dev Behav Pediatr 2019 Jan;40(1):72-74. doi: 10.1097/dbp.0000000000000635..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Autism, Behavioral Health, Case Study
Gu Y, Leroy G, Pettygrove S
Optimizing corpus creation for training word embedding in low resource domains: a case study in Autism Spectrum Disorder (ASD).
Automating the extraction of behavioral criteria indicative of Autism Spectrum Disorder (ASD) in electronic health records (EHRs) can contribute significantly to the effort to monitor the condition. Word embedding algorithms such as Word2Vec can encode semantic meanings of words in vectors and assist in automated vocabulary discovery from EHRs. However, text available for training word embeddings for ASD is miniscule compared to the billions of tokens typically used. In this study, the investigators evaluated the importance of corpus specificity versus size and hypothesized that for specific domains small corpora can generate excellent word embeddings.
AHRQ-funded; HS024988.
Citation: Gu Y, Leroy G, Pettygrove S .
Optimizing corpus creation for training word embedding in low resource domains: a case study in Autism Spectrum Disorder (ASD).
AMIA Annu Symp Proc 2018 Dec 5;2018:508-17..
Keywords: Autism, Electronic Health Records (EHRs), Health Information Technology (HIT)
Leroy G, Gu Y, Pettygrove S
Automated extraction of diagnostic criteria from electronic health records for autism spectrum disorders: development, evaluation, and application.
The objective of this study was to automatically extract from EHRs the description of behaviors noted by the clinicians in evidence of the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The investigators concluded that their results demonstrated that natural language processing can support large-scale analysis useful for autism spectrum disorder surveillance and research.
AHRQ-funded; HS024988.
Citation: Leroy G, Gu Y, Pettygrove S .
Automated extraction of diagnostic criteria from electronic health records for autism spectrum disorders: development, evaluation, and application.
J Med Internet Res 2018 Nov 7;20(11):e10497. doi: 10.2196/10497..
Keywords: Autism, Electronic Health Records (EHRs)
Zuckerman KE, Lindly OJ, Reyes NM
Parent perceptions of community autism spectrum disorder stigma: measure validation and associations in a multi-site sample.
In this study, the investigators developed a brief, English/Spanish bilingual parent-reported scale of perceived community autism spectrum disorder (ASD) stigma and tested it in a multi-site sample of Latino and non-Latino white parents of children with ASD.
AHRQ-funded; HS000063.
Citation: Zuckerman KE, Lindly OJ, Reyes NM .
Parent perceptions of community autism spectrum disorder stigma: measure validation and associations in a multi-site sample.
J Autism Dev Disord 2018 Sep;48(9):3199-209. doi: 10.1007/s10803-018-3586-x..
Keywords: Autism, Disabilities, Social Stigma, Social Determinants of Health, Behavioral Health
Martinez M, Thomas KC, Williams CS
Family experiences with the diagnosis of autism spectrum Disorder: system barriers and facilitators of efficient diagnosis.
This paper examines family experiences with the efficiency of Autism Spectrum Disorder diagnosis. Screening, travel distance, and delay in diagnosis were associated with shifting diagnoses and being told child did not have ASD. Physician and parent training in communication and addressing mental health professional shortages and maldistribution may improve the diagnosis experiences of families of children with ASD.
AHRQ-funded; HS000032.
Citation: Martinez M, Thomas KC, Williams CS .
Family experiences with the diagnosis of autism spectrum Disorder: system barriers and facilitators of efficient diagnosis.
J Autism Dev Disord 2018 Jul;48(7):2368-78. doi: 10.1007/s10803-018-3493-1..
Keywords: Autism, Children/Adolescents, Diagnostic Safety and Quality, Patient-Centered Healthcare, Patient Experience
Lindly OJ, Thorburn S, Heisler K
Parents' use of complementary health approaches for young children with autism spectrum disorder.
Researchers conducted a study to better understand factors influencing parents' decision to use complementary health approaches (CHA) for children with autism spectrum disorder (ASD). CHA use was negatively associated with older child age and positively associated with parents' belief ASD has major consequences and medication use. Nine themes help explain these results.
AHRQ-funded; HS000063.
Citation: Lindly OJ, Thorburn S, Heisler K .
Parents' use of complementary health approaches for young children with autism spectrum disorder.
J Autism Dev Disord 2018 May;48(5):1803-18. doi: 10.1007/s10803-017-3432-6.
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Keywords: Autism, Children/Adolescents, Complementary and Alternative Medicine, Shared Decision Making, Disabilities
Bush RA, Connelly CD, Perez A
Extracting autism spectrum disorder data from the electronic health record.
This study uses electronic health record (EHR) data to examine medical utilization and track outcomes among children with Autism Spectrum Disorder (ASD). The study also identifies challenges inherent in designing inclusive algorithms for identifying individuals with ASD and demonstrates the utility of employing multiple extractions to improve the completeness and quality of EHR data when conducting research.
AHRQ-funded; HS022404.
Citation: Bush RA, Connelly CD, Perez A .
Extracting autism spectrum disorder data from the electronic health record.
Appl Clin Inform 2017 Jul 19;8(3):731-41. doi: 10.4338/aci-2017-02-ra-0029..
Keywords: Autism, Children/Adolescents, Data, Health Information Technology (HIT), Electronic Health Records (EHRs)