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ABSTRACT
BACKGROUND: Attention-deficit/hyperactivity disorder
(ADHD) affects almost 2.4 million US children. Because American Academy of Pediatrics guidelines for ADHD recommend
use of standardized diagnostic instruments, regular follow-up
and the chronic care model, this pilot project sought to implement and assess an electronic registry of patients with ADHD
combined with care coordination by a planned care team.
METHODS: This quality improvement project was structured
with 2 intervention and 2 control clinics to facilitate evaluation
of the use of a planned care system for management of ADHD.
Care teams included a pediatrician, nurse, medical assistant,
and care coordinator and tracked patients using an electronic
registry with data drawn from the EMR. Clinical work flows
were pilot tested to facilitate use of the Vanderbilt scales and
their incorporation into the EMR at intervention sites. Outcome
measures included 2 recommended clinical follow-ups based on
HEDIS measures as well as use of the Vanderbilt rating scales.
Initiation phase measure was for follow-up after initiating medication, while the continuation phase measure was for subsequent follow-up during the first year of treatment. Measures
were monitored during the project year and then also in the
ensuing period of spread of the intervention to other sites.
RESULTS: Although the modified HEDIS initiation phase measure for patients newly on medication remained static at approximately 50% throughout the project period, the continuation
phase measure showed improvement from 35% at baseline to
45% at the end of the project assessment year, a 29% increase.
Follow-up for patients stable on medications also remained unchanged during the project period, but during subsequent
spreading of the intervention to nonproject sites, follow-up of
these patients improved to over 90%. In adjusted analyses, patients with ADHD at intervention sites were over 2 times
more likely than patients at control sites to have had a Vanderbilt score documented in their records.
CONCLUSIONS: The project achieved modest improvements in
the diagnostic and treatment process for patients with ADHD.
The use of a planned care system and electronic patient registry
shows promise for improving the diagnosis and treatment process for patients with ADHD.
KEYWORDS: ADHD; planned care; primary care; quality
improvement; registry
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WHATS NEW
ATTENTION-DEFICIT/HYPERACTIVITY
DISORDER
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METHODS
SETTING
CHA is a large, integrated health system serving Cambridge and Somerville, Massachusetts, as well as Bostons
Metro-North area with a patient population of 25,000 children and approximately 80,000 ambulatory visits per year
at 10 sites. More than half of patients speak a language
other than English at home. Over 50% of the population
is insured by public payers. CHA has previously undertaken QI projects for asthma, immunizations, and mental
health screening. Past projects focused on systems changes
using elements of the chronic care model (registries and
planned care teams) rather than focusing on individual
physician behaviors. Before this ADHD project, CHA
had increased general mental health screening at wellchild visits to over 70% of all patients at every CHA primary care site.21
These past QI projects were implemented by working
with site-based teams and focused on a systems and
process-oriented approach with electronic tools and data
reporting corresponding to the Six Sigma approach to QI.
Six Sigma favors a measurement-based strategy that
focuses on process improvement and reduction in varia-
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AND
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receipt of 2 semiannual visits billed with an ADHD diagnosis in the preceding 12 months. After the project intervention period ended in July 2010, the project team
monitored all reporting metrics through July 2012 to assess
the impact as the intervention was spread to nonproject
clinical sites. Reports continued to be used to the present
by planned care teams in their routine clinical work
(Figure).
Analyses of data were conducted both to help define the
patient population and to detect any demographic variations
in the sample, as well as to assess the impact of the project
on follow-up and use of the Vanderbilt scores. As such, analyses included comparisons between the overall (baseline)
patient populations at the 4 clinics with those in the ADHD
registry and between those at intervention and control sites.
Analyses included bivariate cross-tabs with chi-square tests
for categorical variables and Students t tests for continuous
variables, as well as multivariable logistic regression models
to control for potential confounding. Regression analyses
focused on identifying background factors associated with
the clinical care outcome variable of completion of a Vanderbilt rating scale. On the basis of bivariate analyses, independent variables in the regression models included study
site, gender, age, race/ethnicity, language spoken, and insurance type. Analyses did not control for clustering of effects
by clinician.
RESULTS
PATIENT CHARACTERISTICS
The baseline sample of all children with ADHD diagnosed at the 4 project sites before the annual project period
was 706. Overall, the patients with ADHD differed from
the total pediatric population (n 10,713) with respect
to sex, race/ethnicity, preferred language, and age (all
P < .0001). When compared with the total pediatric population at the 4 clinics, patients with ADHD were more
likely to be male (76% vs 49%) and non-Hispanic white
(49% vs 36%). In addition, patients with ADHD were
more likely to speak English (72% vs 54%) and to be
slightly older (mean age 12.8 years vs 11.9 years).
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Table 1. Comparative Characteristics of Patients Newly Diagnosed With ADHD During Project Period by Clinical Site*
All
Characteristic
Total
Sex
Male
Female
Age
Years, mean (SD)
Race/ethnicity
White
Black
Hispanic
Other
Missing
Language of medical care
English
Portuguese
Spanish
Other
Insurance
Public or self-pay
Private
Current ADHD diagnosis
By DX only
By medication only
By DX and medication
Number of Visits
One
Two
Three or more
Mean (SD)
Any ADHD assessment tool in chart
Vanderbilt score (teacher, parent, or both)
Other (Connor or unspecified)
None
BMI measurement in chart during project period
Yes
No
73
51
22
Intervention Sites
%
33
69.9
30.1
11.3 (3.9)
19
14
Control Sites
n
80.0
20.0
.038
40
57.6
42.4
10.9 (3.8)
32
8
11.6 (4.0)
.41
31
17
12
11
2
43.7
23.9
16.9
15.5
.
11
7
10
3
.
35.5
22.6
32.3
9.7
.
20
10
2
8
.
50.0
25.0
5.0
20.0
.
.02
57
9
4
3
78.1
12.3
5.5
4.1
25
2
3
3
75.8
6.1
9.1
9.1
32
7
1
0
80.0
17.5
2.5
0.0
.06
44
29
60.3
39.7
17
16
51.5
48.5
27
13
67.5
32.5
.16
45
11
17
61.6
15.1
23.3
18
5
10
54.6
15.2
3.3
27
6
7
67.5
15.0
17.5
.41
19
19
35
2.2 (0.84)
26.0
26.0
48.0
6.1
27.3
66.7
17
10
13
1.9 (0.87)
42.5
25.0
32.5
.001
25
1
47
34.3
1.4
64.4
16
0
17
48.5
.0
51.5
9
1
30
23.1
2.5
76.9
.024
50
23
68.5
31.5
23
10
69.7
30.3
27
13
67.5
32.5
.84
2
9
22
2.6 (0.61)
.0001
After data cleaning at the onset of the project, 256 children were in the target age range, were actively receiving
medications for ADHD, and were managed by a PCP at
the 4 sites (as opposed to a child psychiatrist). In addition,
73 more children were diagnosed and managed by the PCP
during the project period, for a total of 329 subjects. Newly
diagnosed patients at intervention sites had more office
visits during the project time period (mean of 2.6 vs 1.9,
P .0001), and in unadjusted analyses, a larger proportion
had completed Vanderbilt assessments compared to the
patients diagnosed at control sites (48.5% vs 23.1%,
P .024) (Table 1).
MODIFIED HEDIS MEASURES AND SEMIANNUAL VISITS
Initial assessment of the modified HEDIS measures from
data at the end of the intervention period in June 2010 at the
2 intervention sites revealed 53% of pediatricians to have
met the initiation phase requirement and 35% to have met
the continuation phase requirement. In the next review of
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Table 2. Adjusted Odds of Having Vanderbilt Score Completion in Patients Diagnosed With ADHD Stratified by Timing of Diagnosis in Relation to QI Project Period, FebruaryAugust 2010
All Patients With
ADHD (n 321)
Previously Diagnosed
(n 250)
Newly Diagnosed
(n 71)
Independent Variable
OR
95% CI
OR
95% CI
OR
95% CI
2.43**
2.55**
0.78****
0.92
0.94
0.72
2.84*
2.16
1.48
1.254.76
1.295.07
0.700.86
0.441.94
0.491.81
0.301.73
1.206.68
0.855.49
0.732.98
2.25*
NA
0.80***
0.81
1.29
0.96
2.54
2.65
1.33
1.024.99
1.91
NA
0.70**
2.41
0.33
0.31
5.04
1.28
2.11
0.487.68
0.710.91
0.322.01
0.582.89
0.342.67
0.917.08
0.897.86
0.583.04
0.550.88
0.4413.2
0.091.30
0.051.93
0.7932.1
0.1610.5
0.459.81
ADHD indicates attention-deficit/hyperactivity disorder; QI, quality improvement; OR, odds ratio; and CI, confidence interval.
*P < .05.
**P < .01.
***P < .001.
****P < .0001.
DISCUSSION
This ADHD planned care project using a patient registry
resulted in increased follow-up care for patients newly
prescribed medication over the course of the project period
as well as improved use of the Vanderbilt rating scale.
Given the relatively low rates of follow-up at the end of
the intervention period, however, more room for improvement existed. During the 3 years after the formal QI
project, in which the planned care process was spread to
other CHA sites, we have documented notable ongoing
improvement. The most recent rate of having 2 visits in
the preceding 12-month period for children who receive
medication for ADHD prescribed by their PCP at all
CHA clinical sites was 93% for the AprilJune 2014 quarterly measurement period.
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ACKNOWLEDGMENTS
This project was funded by a pilot grant from the Harvard Catalyst, The
Harvard Clinical and Translational Science Center (DA Link, PI). The
funder had no role in the design and conduct of the project or preparation
of this document.
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