Abstract
Sleep is crucial for healthy growth, academic success, executive functioning, and mental health. However, sleep is not consistently and rigorously addressed in pediatric primary care.
To describe the development and reach, adoption, implementation, effectiveness, and maintenance of a well-child visit, electronic sleep screener with educational resources in a large primary care network.
In this case-control study of primary care practices in Pennsylvania and New Jersey, retrospective, observational electronic health records and implementation data were drawn for preimplementation (November 1, 2018, to September 30, 2019), phased-scaling (October 1, 2019, to June 30, 2021), implementation (July 1, 2021, to June 30, 2022), and maintenance (July 1, 2022, to June 30, 2023) periods. Multivariate logistic regression examined the effectiveness by comparing implementation vs preimplementation rates of sleep disorder diagnosis, polysomnogram orders, and sleep-related referrals. Patients were seen for a well-child visit during the preimplementation and implementation periods, without exclusions. Data were analyzed from October 10, 2023, to May 2, 2025.
An age-based, electronic sleep screener assessing infant bed sharing, frequent snoring (≥3 nights/week), perceived sleep problems, insufficient sleep duration, and adolescent daytime sleepiness.
The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework guided the outcomes including sleep screener use, results, and primary care clinician (PCC)-rendered sleep disorder diagnosis, polysomnogram orders, and sleep-related referrals at the well-child visit.
A total of 409 217 well-child visits for 288 307 unique patients aged 18 years or younger (51.2% male; 49.9% White non-Hispanic or Latine) were included in the preimplementation and implementation periods. During implementation, 204 872 unique patients in 31 practices completed the screener, with adoption in 89.5% of all well-child visits. Overall, 9.7% of patients endorsed frequent snoring, 12.2% sleep problems, and 34.4% insufficient sleep. Infant bed sharing was endorsed in 6.5% of infants, whereas 14.7% of adolescents endorsed daytime sleepiness. Compared with the preimplementation period, at well-child visits with a completed sleep screener, PCCs were significantly more likely to render a sleep disorder diagnosis (odds ratio, 1.64 [95% CI, 1.56-1.73]), order a polysomnogram (odds ratio, 2.67 [95% CI, 2.32-3.20]), and refer to sleep (odds ratio, 6.48 [95% CI, 5.03-8.34]) or otolaryngology (odds ratio, 4.46 [95% CI, 3.95-5.02]) clinics. Minimal adaptations occurred during implementation, and adoption was high and persistent (92.5% of well-child visits) during the maintenance period.
In this case-control study, a brief, electronic well-child visit sleep screener was widely adopted and maintained in a sociodemographically diverse primary care network and was associated with increased recognition and management of sleep problems.