By Will Boggs MD
NEW YORK - Many children with attention deficit-hyperactivity disorder (ADHD) receive care that falls short of standards published by the American Academy of Pediatrics (AAP) more than a decade ago, according to a review of medical charts.
Dr. Jeffery N. Epstein from Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio was not really surprised at the findings.
"The American Academy of Pediatrics published a rigorous set of evidence-based recommendations for pediatricians regarding the provision of ADHD care," he told Reuters Health. "These recommendations can be quite difficult to implement in a typical pediatric practice due to time and resource constraints."
"For example, to collect teacher ratings of a child's ADHD behavior, which is a critical piece of the ADHD assessment and diagnostic process, pediatricians need to provide parents with the rating scale, rely on the parents to deliver the rating scale to the teacher, hope that the teacher completes the rating scale and returns it to the parent, then the parent has to deliver it back to the pediatrician," he explained. "Moreover, once the completed rating scale arrives, it needs to be scored, interpreted, and read by the pediatrician. It is a lot of steps, and these steps can be difficult to manage in a typical pediatric setting."
To assess how well community-based pediatrics practices were doing, Dr. Epstein's team reviewed 1594 charts of children with ADHD seen by 188 pediatricians at 50 different practices in central and northern Ohio.
During the diagnostic process, pediatricians used parent ratings of ADHD only 56.7% of the time and used teacher ratings (as in the example above) only 55.5% of the time.
Documentation that the child met DSM-IV criteria for ADHD appeared in only 70.4% of the charts, the authors reported November 3rd online in Pediatrics.
Pediatricians prescribed medication for 93.4% of children diagnosed with ADHD, but documentation that psychosocial treatment was recommended or actually used by families appeared in only 13.0% of the charts.
Once they prescribed medications, pediatricians did not see the patient again for an average of 72.4 days. The second contact occurred an average of 147.7 days after the initial prescription, and the third contact occurred an average of 226.4 days after the initial prescription. Children averaged 5.7 contacts in their first year of treatment.
During the second year of treatment, children averaged 3.1 contacts with their pediatrician, and this fell further, to 2.8 contacts, during the third year of treatment.
Only 10.8% of charts had evidence of parental ratings and only 7.5% had evidence of teacher ratings for monitoring treatment response and side effects within the first year of treatment. Even these took an average of about a year after prescribing medication before they were recorded.
As the proportion of Medicaid patients increased, rates of psychosocial treatment increased at nonacademic practices but decreased at academic practices.
Pediatricians at urban settings prescribed medication more often than did suburban pediatricians, whereas urban and rural pediatricians used psychosocial treatment more frequently than suburban pediatricians.
The interdependence among practice characteristics precluded the identification of independent effects of any single predictor on the quality of care.
"Because pediatricians and practices were associated with variability in rates of ADHD care behaviors across patients," the researchers say, "we believe that the adoption of pediatrician- or practice-level modifications to ADHD systems of care can improve these areas of care."
"Some efforts are being made to improve the quality of care in pediatric settings," Dr. Epstein said. "For example, the American Board of Pediatrics now has a requirement that all pediatricians participate in quality improvement activities in order to get re-licensed."
"Many pediatricians are choosing to focus on improving their own ADHD care," he said. "Perhaps, to address these facets of ADHD care, there is a need for health care/insurance reforms that would incentivize (e.g., pay-for-performance) pediatricians to implement these more difficult ADHD care behaviors."
Daniel J. Wagner, a graduate student specializing in Health Services Research at University of Toronto, Toronto, Ontario, Canada, has published research on ADHD. He told Reuters Health, "I was most surprised by the reported length of time to collect parent and teacher ratings to monitor treatment response. Paired with low reports of parent and teacher data at assessment, I wonder if there is much value in the collection of data more than a year later on the provision of care to these patients."
"The expectation that clinics adhere to all elements of best-practice guidelines or recommendations may not be the right step," Wagner said. "However, one element which should be considered is the routine collection of parent and teacher data. In time, this may enable the development of benchmark outcomes to aid in evaluating the effectiveness of different clinical services."
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