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Quality of community-based ADHD care needs improvement
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Recent data indicate community-based ADHD care is inconsistent with evidence-based practice guidelines; however, some variability is unrelated to the physician.
Jeffery N. Epstein, PhD, of Cincinnati Children’s Hospital, and colleagues reviewed 1,594 patient charts from 188 health care providers in 50 pediatric practices in central and northern Ohio. Information from patient charts for any ADHD care received between 2002 and 2012 was reviewed.
Health care providers had a mean age of 43.5 years and had an average of 12.9 years since finishing their training.
During the diagnostic process, physicians utilized parent and teacher ratings of ADHD 56.7% and 55.5% of the time, respectively. Meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for ADHD was documented in patient charts 70.4% of the time. Most of the variability in assessment occurred at the patient level, according to researchers, but significant variability also occurred at the pediatrician and practice levels.
Pediatricians prescribed medication to 93.4% of the 1,098 children assessed for ADHD. Psychosocial treatment (ie, parent training, therapy) was documented as recommended or used by families in 13% of patient charts. Most variability regarding medication and psychosocial treatment occurred at the patient level, according to researchers; however, significant variability for psychosocial treatment occurred at the pediatrician and practice levels.
Approximately 47.4% of children with at least 30 days between prescribing medication and chart review (n=1,518) had visit or phone contacts within the first month of medication prescription. Of these, 53% had at least one office visit; 35% had at least one phone contact and 12% had at least one visit and one phone contact.
In the first year of treatment, children with at least 1 year between prescribing medication and chart review averaged 5.7 contacts. Most of these contacts were office visits and 1.3 contacts per year occurred via phone. Fewer contacts occurred during the second and third years of treatment, according to the researchers.
Approximately 10.8% of patient charts documented parent ratings within the first year of treatment, and 7.5% documented teacher ratings.
Though significant variability occurred at the pediatrician and practice level for contact within the first month, most variability regarding patient-physician contact and follow-up practices occurred at the patient level, according to the researchers.
Reported proportions of Medicaid patients varied from 0% to 99%, with a mean of 44.6%. Less than half of physicians (25%) reported affiliations with an academic medical center.
According to researchers, the rate of psychosocial treatment increased at nonacademic practices and decreased at academic practices as the number of Medicaid patients at a practice increased. However, analysis indicated no associations between Medicaid percentage and academic affiliation. Further, longer time to collecting parent ratings to monitor treatment response was linked with having more Medicaid patients, according to the researchers.
Fifty-three pediatricians reported urban setting locations; 103 reported suburban locations and 17 reported rural locations. Pediatricians in suburban areas were less likely than those in urban or rural areas to use medications and psychosocial therapy. However, patients at suburban practices had shorter durations between medication initiation and first contact compared with those at urban practices.
Eighty-three percent of academic practices served a Medicaid population, compared with nonacademic practices that averaged 33% Medicaid patients (P<.0001). Approximately 26.5% of patients in suburban practices utilized Medicaid, compared with 47.9% in rural practices and 78.1% in urban practices.
Academic practices were predominantly located in urban areas and accounted for 64.3% of urban practices. Three percent of academic practices were in suburban areas. No academic practices were in rural locations.
“The results of this study suggest that current pediatrician-delivered ADHD care leaves much room for improvement,” the researchers wrote. “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.”
Disclosure: The researchers report no relevant financial disclosures.
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