Community-Based ADHD Care Leaves 'Room for Improvement'

Diana Phillips

November 03, 2014

Community-based care for children with attention-deficit/hyperactivity disorder (ADHD) varies substantially and is not consistent with evidence-based practice, according to results from a new study.

The findings, published November 3 in Pediatrics, "suggest that current pediatrician-delivered ADHD care leaves much room for improvement," according to principal investigator Jeffrey N. Epstein, PhD, from the Department of Pediatrics at Cincinnati Children's Hospital Medical Center in Ohio, and colleagues.

In the study, pediatricians across 50 socioeconomically and demographically diverse practices in Central and Northern Ohio used Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition, criteria in approximately two thirds of patients during ADHD assessment, and they used parent and teacher rating scales in approximately half of patients, despite American Academy of Pediatrics consensus guidelines recommending both, the authors note.

The American Academy of Pediatrics clinical practice guideline, issued in 2001, recommends the use of explicit Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition, criteria for ADHD diagnosis and stresses the importance of obtaining information about the child's symptoms in more than one setting, especially from schools.

With respect to treatment, the majority of patients with ADHD included in the current analysis received medication, although few received psychosocial treatment, "even though combined treatment is the most effective treatment strategy for children with ADHD," the authors write.

To investigate rates and sources of variability in ADHD care and to evaluate the relationship between practice characteristics and ADHD care, the investigators recruited practices with at least two pediatricians and no access to onsite mental health services from Central and Northern Ohio from August 2010 through December 2012. The researchers included the first 50 pediatric practices (188 healthcare providers) that responded and met the inclusion criteria in the analysis.

The investigators reviewed the charts of a random sample of 1594 patients across the practices to calculate rates of evidence-based ADHD care and identify variability at the practice, pediatrician, and patient levels. They also examined associations of Medicaid status and practice setting with the quality of ADHD care. Of the 1594 charts the researchers reviewed, 1098 provided information about both ADHD assessment and treatment and 496 included information about treatment only, the authors note.

"Pediatricians used parent and teacher ratings of ADHD during the ADHD diagnostic process 56.7% (SE 3.7%) and 55.5% (SE 3.6%) of the time, respectively," the authors write. "Evidence of children meeting [Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition] criteria for ADHD was documented in patient charts 70.4% (SE 3.4%) of the time." With respect to the assessment variables, most of the variability was at the patient level, although significant variability also existed at both the pediatrician and practice levels, they observe.

Medication was prescribed for 93.4% of the children assessed for ADHD, whereas documentation of the recommendation or use of psychosocial treatment was present for only 13.0% of the children. "Most of the variability on these 2 variables was accounted for at the patient level. However, significant variability for the psychosocial treatment variable also was also present at the pediatrician and practice levels," the authors state.

The use of objective ratings to monitor treatment response was rare within the first year of treatment, the authors write, noting that 10.8% and 7.5% of patient charts, respectively, had evidence of parent or teacher ratings. "Most of the variability in patterns of ADHD treatment contacts and follow-up practice behavior occurred at the patient level," they report, although significant variability also occurred at the pediatrician and practice level for some ADHD care treatment variables, such as contact within the first month.

Multilevel models to determine whether receiving Medicaid assistance influenced ADHD care variables showed that Medicaid status was associated with longer times until the collection of parent ratings to monitor response. "However, for other indicators of ADHD care quality, Medicaid status was not associated with worse ADHD care," the authors write.

Of interest, the authors note, is the observation that increasing proportions of Medicaid patients were associated with higher rates of psychosocial treatment at nonacademic practices, whereas higher rates of Medicaid patients led to lower rates of psychosocial treatment at academic practices. "Perhaps academic pediatricians refer within their affiliated medical center, which may have long waits for psychosocial treatment and these delays lead to lower rates of psychosocial treatment," they suggest.

Children seen for ADHD by pediatricians in a suburban setting were less likely to be prescribed medication after an ADHD diagnosis compared with urban patients, and suburban patients had lower rates of psychosocial treatment than urban or rural patients, the findings show. "One possible explanation is that there was reluctance or delays [either by providers or families] in suburban settings toward beginning treatment or accepting the diagnosis. Alternatively, patients in urban settings may have presented with more severe symptoms requiring immediate initiation of treatment," the authors note.

The findings point to the need for improvements in the quality of ADHD care, the authors write. "Although guidelines are an important first step, additional efforts, likely initiated or incentivized outside the practice, are required to improve the quality of care delivered in pediatric settings. Such efforts," they continue, "may take the form of quality improvement, clinical decision support tools, using pay-for-performance incentives, and/or partnering with mental health professionals."

This study was supported by the National Institutes of Health. The authors have disclosed no relevant financial relationships.

Pediatrics. Published online November 3, 2014. Abstract

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