December 29, 2010 — There is a substantial need for improved quality of care for Medicaid-funded attention-deficit/hyperactivity disorder (ADHD) treatment for children, new research suggests.
Among other findings, a cohort study of more than 500 children with ADHD shows that clinical outcomes in this patient population including ADHD symptoms, functioning, academic achievement, parental distress, perceived benefit of treatment, and improved family functions were similar among children who remained in care and children who received no care at all.
The study also revealed that both the primary and specialty care groups had little crossover, similar clinical severity of ADHD, and similarly high drop-out rates, and more than one third of the children in both groups failed to continue taking prescribed stimulant medication.
Children in the primary care group predominantly received medication but had "negligible" follow-up visits of roughly 1 to 2 per year. In contrast, almost the entire specialty mental healthcare group received some type of psychosocial intervention, with about 5 visits per month, but less than one third of these children were prescribed any stimulant medication.
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| Dr. Bonnie T. Zima |
"We wanted to look at how well this vulnerable group of young patients was faring in the managed care Medicaid system. And we were surprised to find that quality was poor in both the primary care and specialty care sectors, but for different reasons," Bonnie T. Zima, MD, MPH, professor of child and adolescent psychiatry at the University of California–Los Angeles, told Medscape Medical News.
Dr. Zima added that "this is of high public significance," noting that ADHD is the most common childhood psychiatric disorder, affecting between 3% and 7% of all children in the United States. She pointed out that the disorder has established treatment protocols and can persist into adolescence and adulthood, with devastating long-term consequences.
The study appears in the December issue of the Journal of the American Academy of Child and Adolescent Psychiatry.
Lack of Coordinated Care
The investigators evaluated data on 530 children between the ages of 5 and 11 years (mean age, 9.9 years; 68% boys; 54% Latino, 23% black, 13% white, 10% from more than 1 ethnic background) diagnosed with ADHD.
All children received outpatient care in a primary care setting or at specialty mental health clinics in Los Angeles County between November 2004 and September 2006.
Information was collected for all participants from Medicaid service and pharmacy claims data and school records. In addition, parent and child interviews were conducted in homes, with follow-up telephone surveys given approximately 6 and 12 months later.
Results showed that 34% of all participants received no care of any type during the 6 months before the baseline interview, and 44% received no care between the 6- and 12-month follow-up time points. Among those in the primary care group only, 52% received no care between the 2 follow-up times.
A total of 13% to 20% of all participants did not receive any care for their ADHD diagnosis during the time points.
There was little crossover between the 2 sectors, meaning none of the children who began treatment in primary care had additional contact with specialty mental healthcare, and vice versa.
"This prevented the 2 sectors from coordinating care and shows that more efforts are needed to improve this coordination," said Dr. Zima.
Failure to Meet Institute of Medicine Standard
In primary care, 80% to 85% of the children had at least 1 stimulant prescription filled during 1 of the study time points, which is recommended care for ADHD, and 95% to 98% had at least 1 psychotropic medication filled. A total of 22% to 26% received a stimulant plus other type of psychotropic.
"That there were only 1 to 2 follow-up visits a year by the children in primary care is a concern because those receiving stimulant medication require more frequent monitoring," explained Dr. Zima. "We also anticipated higher rates of stimulant use in the mental health clinics."
Instead, "the rates of stimulant medication treatment in primary care clinics was consistently at least 2.8 times greater than that found in specialty mental health programs over the 3 time intervals," the authors write.
However, stimulant medication refill prescription persistence was poor in both sectors and ranged from 33% to 44% in primary care and 31% to 49% in specialty mental healthcare. More than 90% of the children in the specialty mental care group received some type of psychosocial intervention, with more than 75% receiving psychotherapy at each time point.
The receipt of combined psychosocial treatment and any medication at each time interval was between 26% and 43% for both care groups. In addition, almost one third of all children dropped out of care. This drop-out rate increased to 50% for those who had received primary care services.
Finally, behavior therapy or parent training documentation was missing in the agency databases for both sectors.
"Care for childhood ADHD in the [studied] Medicaid program failed to meet the Institute of Medicine's definition of quality that requires 'consistency with current professional knowledge' and 'improved likelihood of destined health outcomes,' " the authors write.
Room for Improvement
Areas identified for needing quality improvement included "alignment of clinical severity with provider type, follow-up visits, stimulant use in specialty mental health, agency data infrastructure to document delivery of evidence-based psychosocial treatment, and stimulant medication refill prescription persistence," they add.
They point out that these findings are especially important, as almost 4.1 million additional children are expected to enter the Medicaid-funded healthcare system by the year 2013, in large part because of the recently enacted Patient Protection and Affordable Care Act, which will expand Medicaid eligibility.
"Healthcare reform has put a big investment in improving access to public insurance for children, but this study points to [areas] where we need to invest in improving quality of care for the children receiving public insurance," said Dr. Zima.
"The timing of this study is very exciting, not just because of the healthcare reform legislation but also because 1 of the first pieces to be passed by the Obama administration was the Child Health Insurance Program Reauthorization Act. That's important because there's funding now tied into that legislation to begin to develop better measures of quality of care for children. And one of the priority areas is mental health," said Dr. Zima.
These findings also strongly suggest that we need to do a better job of supporting our families of high-risk kids, to help them follow-up with their visits, and that we have much more work ahead of us to help improve medication adherence.
"Hopefully, with healthcare reform, we'll be able to develop new models of care that will integrate mental healthcare with primary care for children. These findings also strongly suggest that we need to do a better job of supporting our families of high-risk kids, to help them follow-up with their visits, and that we have much more work ahead of us to help improve medication adherence," she added.
Renewed Urgency for Reform
"Although it has been known for many years that the treatment of ADHD is often shallow and uneven, the portrait of community care that emerges from the study by Zima et al is considerably more detailed and stark than previous assessments," said Mark Olfson, MD, MPH, from the New York State Psychiatric Institute and the College of Physicians and Surgeons of Columbia University in New York City, in an accompanying editorial.
"The results reveal a failure to allocate specialty services to those in greatest clinical need, widespread deficiencies in pharmacologic treatment, high rates of treatment disengagement, and unacceptably poor clinical and academic outcomes," added Dr. Olfson.
He notes that this study "adds renewed urgency to the call for reform of Medicaid-financed community care" for these children, including closer clinical monitoring, improved medication management, and greater attention given to assessment and referral procedures.
In this challenging environment, it will be critically important to maintain focus on the quality of care provided to children and adolescents in the Medicaid program who have ADHD.
"Sustained progress in each of these key areas will likely require interventions at the patient, parent, clinician, and system levels," he writes.
"In this challenging environment, it will be critically important to maintain focus on the quality of care provided to children and adolescents in the Medicaid program who have ADHD," he concludes.
The study was funded by the National Institute of Mental Health. One study author reports being a consultant to or receiving honoraria from Shire and from Eli Lilly and Company, and currently receives research support from Forest, Pfizer, and Shire. The other study authors, including Dr. Zima, have disclosed no relevant financial relationships. Dr. Olfson reports receiving research grants to Columbia University from Eli Lilly and Company and from Mental Health Therapeutics.
J Am Acad Child Adolesc Psychiatry. 2010;49:1225-1237, 1183-1185. Abstract Abstract
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