Use of an Internet portal to improve community-based pediatric ADHD care: a cluster randomized trial

A Quality Improvement Initiative for Detection of Attention-Deficit/Hyperactivity Disorder in an Urban, Academic Safety Net Hospital

OBJECTIVE

Improve detection of Attention Deficit/Hyperactivity Disorder (ADHD) in a safety net, hospital-based, academic pediatric practice by optimizing screening with the Pediatric Symptom Checklist attention score (PSC-AS) and further evaluation with the Vanderbilt ADHD Diagnostic Rating Scale (VADRS).

METHODS

We implemented a multi-component intervention by (1) optimizing electronic medical record (EMR) features; (2) adjusting clinic operational workflow; and (3) creating a decision-making algorithm for pediatric primary care clinicians (PPCCs). We extracted 4 outcomes manually from the EMR (pediatrician acknowledgment of a positive PSC-AS, documentation of a plan for further evaluation, distribution of VADRS, and completion of at least 1 VADRS). Outcomes were measured monthly in run charts compared to the pre-intervention control period, and implementation was optimized with Plan-Do-Study-Act cycles.

RESULTS

PPCCs were significantly more likely to acknowledge a positive PSC-AS in the intervention versus control (65.3% vs 41.5%; p < 0.001), although this did not change documentation of a plan (70% vs 67.1%; p -value = 0.565). Significantly more children with a positive PSC-AS were distributed a parent or teacher VADRS in the intervention versus control (30.6% vs 17.7%; p -value = 0.0059), but the percentage of returned VADRS rating scales did not improve (12.9% vs 9.2%; p -value = 0.269).

CONCLUSION

Our ADHD detection quality improvement initiative improved use of the PSC-AS to identify attention problems and distribution of VADRS diagnostic rating scales, but additional interventions are needed to improve the completion of ADHD evaluations in primary care to ensure that children are appropriately identified and offered evidence-based care.

A meta-analysis on the effect of telemedicine on the management of attention deficit and hyperactivity disorder in children and adolescents

INTRODUCTION

This study aims to report the effect sizes of telemedicine treatments on the symptom domains of paediatric ADHD.

METHODS

In this systematic review and meta-analysis, electronic databases, i.e. PubMed, Scopus, Web of Science and Embase, were searched for articles published up to December 2020. The inclusion criteria were as follows: children or adolescents diagnosed for ADHD or other hyperkinetic disorders; randomized controlled trials (RCTs); efficacy established with parents and teachers or self-rating scales at least for one of the following domains: inattention, cognitive function, hyperactivity, hyperactivity/impulsivity or oppositional behaviours. The risk of bias was assessed using the Cochrane risk of bias tool for RCTs.

RESULTS

From 310 records reduced to 228 after removing duplicates, overall 12 studies were fulfilled our inclusion criteria. They consisted of 708 participants (358 with telemedicine intervention and 350 controls). The telemedicine interventions varied from computerized training programmes with phone calls to videoconferencing programmes, virtual reality classrooms or games. The most applicable method consisted of computerized training programmes with phone calls. Pooling results of all studies with available data on each subscale showed a significant effect of telemedicine on inattention/cognitive function (standardized mean difference (SMD) = 0.26, 95% CI: 0.16, 0.36), hyperactivity/impulsivity (SMD = 0.29, 95% CI: 0.06, 0.52), and oppositional behaviours (SMD = 0.72, 95% CI: 0.24, 1.20) subscales in ADHD. Almost all studies had an overall unclear risk of bias. The source of outcome assessment (parents, teachers or self-report questionnaire) was addressed as a potential confounding factor. In almost all symptom domains, the satisfaction from the treatment was higher in parents than in teachers.

CONCLUSIONS

The clinical effects of telemedicine on the treatment of ADHD showed a small effect size for inattention/cognitive function, hyperactivity/impulsivity and oppositional behaviours.

Assessment and Management of Attention-Deficit/Hyperactivity Disorder: Pediatric Resident Perspectives on Training and Practice

Attention-deficit/hyperactivity disorder (ADHD) is a common presenting concern in primary care. This study examined the relationship between pediatric residency training program characteristics and residents' ADHD knowledge, attitudes, and comfort in providing ADHD services. Given the familiarity that pediatric chief residents have with the training and experiences within their residency programs, a 30-item survey was mailed to pediatric chief residents. A total of 100 residents returned their surveys (response rate 49.5%) and were included in the descriptive quantitative and thematic qualitative analyses. The majority of participants rated their ADHD knowledge as at least average. However, approximately half of the participants were comfortable with screening, and less than half were comfortable with managing stimulant medication or behavioral treatments. Participants emphasized the importance of interprofessional collaboration, clinical experiences, and integrated ADHD education throughout training. These results emphasize the importance of improved training in screening, diagnosing, and managing ADHD to increase resident comfort regarding these practices.

Adherence to Clinical Guidelines for Dose Finding and Monitoring Methylphenidate Use: A Medical Record Audit in Child and Adolescent Mental Health Care and Pediatric Settings

Background: Guideline adherence is important to ensure optimal and safe use of methylphenidate for children and adolescents with attention-deficit/hyperactivity disorder (ADHD). We investigated adherence to Dutch guidelines regarding dosing and monitoring of methylphenidate in child and adolescent mental health care and pediatric treatment settings. Methods: Five hundred six medical records of children and adolescents were investigated in 2015 and 2016. We assessed adherence to the following guideline recommendations: (1) at least four visits during the dose-finding phase; (2) monitoring thereafter at least every 6 months; (3) measuring height and weight at least annually; and (4) the use of validated questionnaires to assess treatment response. Pearson's chi-squared test statistics were used to examine differences between settings. Results: Only a small portion of patients had at least four visits during the dose-finding phase (5.1% in the first 4 weeks to 12.4% in the first 6 weeks). Also, less than half of the patients (48.4%) were seen at least every 6 months. Height was recorded at least annually in 42.0% of patients, weight in 44.9%, and both recorded in a growth chart in 19.5%. Questionnaires to assess treatment response were only used in 2.3% of all visits. When comparing both settings, more patients in the pediatric settings were seen every 6 months, although height and weight were recorded more often in the mental health care setting. Conclusion: Overall, guideline adherence was low. Training of clinicians and adding guideline recommendations to electronic medical records templates may improve adherence. Additionally, we should aim to close the gap between guidelines and clinical practice by looking critically at the feasibility of guidelines.

Clinicians' Adherence to Guidelines When Initiating Methylphenidate Treatment

Aims: Between 2008 and 2012, the number of children and adolescents in the Netherlands who received methylphenidate prescriptions increased by 35.6%. We determined guideline adherence regarding the assessment of attention-deficit/hyperactivity disorder (ADHD) and rates of off-label use in those 2 years. We also compared adherence to guidelines between mental health and pediatrics settings. Methods: We conducted a medical file audit of 506 children or adolescents who had received a first methylphenidate prescription in 2008 (n = 208) or 2012 (n = 298) across mental health (n = 333) and pediatrics outpatient clinics (n = 173) in the Netherlands and assessed adherence to seven guideline recommendations. Results: We did not find significant differences between 2008 and 2012 regarding the mean adherence to the seven recommendations (43% vs. 45%) or the percentage of off-label use (35% vs. 30%). Best adherence rates (over the years 2008 and 2012 combined) concerned the assessment of comorbidities (89%) and the involvement of teachers in the diagnostic process (75%). Least frequently adhered to were assessing ADHD severity (1%), the use of a (semi-)structured parent interview (16%), and providing psycho-education to parents (42%) or teachers (1%). Mental health settings showed better adherence than pediatrics settings (over the years 2008 and 2012 combined) concerning the use of (semi-)structured parent interviews (22% vs. 3.1%), having a separate diagnostic session directed at the child (81% vs. 63%), assessment of comorbidities (95% vs. 76%), and providing psycho-education to parents (51% vs. 24%). Conclusions: There was neither a decrease in adherence to guidelines nor an increase in off-label use between 2008 and 2012. However, there is ample room for improvement regarding guideline adherence.

Efficacy of Online Intervention for ADHD: A Meta-Analysis and Systematic Review

Background

With the popularity of computers, the internet, and the global spread of COVID-19, more and more attention deficit hyperactivity disorder (ADHD) patients need timely interventions through the internet. At present, there are many online intervention schemes may help these patients. It is necessary to integrate data to analyze their effectiveness.

Objectives

Our purpose is to integrate the ADHD online interventions trials, study its treatment effect and analyze its feasibility, and provide reference information for doctors in other institutions to formulate better treatment plans.

Methods

We searched PubMed, EMBASE and Cochrane libraries. We didn't limit the start date and end date of search results. Our last search was on December 1, 2021. The keyword is ADHD online therapy. We used the Cochrane bias risk tool to assess the quality of included studies, used the standardized mean difference (SMD) as an effect scale indicator to measure data. Random effects model, subgroup analysis were used to analyze the data.

Results

Six randomized controlled trials (RCTs) were identified, including 261 patients with ADHD. These studies showed that online interventions was more effective than waiting list in improving attention deficit and social function of adults and children with ADHD. The attention deficit scores of subjects were calculated in six studies. The sample size of the test group was 123, the sample size of the control group was 133, and the combined SMD was −0.73 (95% confidence interval: −1.01, −0.44). The social function scores of subjects were calculated in six studies. The sample size of the experimental group was 123 and the control group was 133. The combined SMD was −0.59 (95% confidence interval: −0.85, −0.33).

Conclusions

The results show that online interventions of ADHD may be an effective intervention. In the future, we need more online intervention researches to improve the symptoms of different patients, especially for some patients who have difficulties in accepting face-to-face treatment.

Perspectives of Rural Primary Care Clinicians on Pediatric Attention-Deficit/Hyperactivity Disorder Care

OBJECTIVE

Despite efficacious treatments, evidence-based guidelines, and increased availability of integrated behavioral health care, youth coping with attention-deficit/hyperactivity disorder (ADHD) receive suboptimal care. More research is needed to understand and address care gaps, particularly within rural health systems that face unique challenges. We conducted a qualitative study within a predominantly rural health system with a pediatric-integrated behavioral health care program to address research gaps and prepare for quality improvement initiatives, including primary care clinician (PCC) trainings and clinical decision support tools in the electronic health record (EHR).

METHOD

Semistructured interviews were conducted with 26 PCCs representing clinics within the health system. Interview guides were based on the Practical Robust Implementation and Sustainability Model to elicit PCC views regarding determinants of current practices and suggestions to guide quality improvement efforts. We used thematic analysis to identify patterns of responding that were common across participants.

RESULTS

PCCs identified several internal and external contextual factors as determinants of current practices. Of note, PCCs recommended increased access to continuing education trainings held in clinic over lunch and delivered in less than 30 minutes. Suggested improvements to the EHR included incorporating parent and teacher versions of the Vanderbilt Rating Scale into the EHR, documentation templates aligned with evidence-based guidelines, and alerts and suggestions to aid medication management during appointments.

CONCLUSION

Future research to identify implementation strategies to help rural PCCs adopt innovations are needed given the increased responsibility for managing ADHD care and intractable gaps in access to behavioral health care in rural regions.

Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood neurodevelopmental disorder and is associated with an array of coexisting conditions that complicate diagnostic assessment and treatment. ADHD and its coexisting conditions may impact function across multiple settings (home, school, peers, community), placing the affected child or adolescent at risk for adverse health and psychosocial outcomes in adulthood. Current practice guidelines focus on the treatment of ADHD in the primary care setting. The Society for Developmental and Behavioral Pediatrics has developed this practice guideline to facilitate integrated, interprofessional assessment and treatment of children and adolescents with "complex ADHD" defined by age (<4 years or presentation at age >12 years), presence of coexisting conditions, moderate to severe functional impairment, diagnostic uncertainty, or inadequate response to treatment.

Continuing education meetings and workshops: effects on professional practice and healthcare outcomes

BACKGROUND

Educational meetings are used widely by health personnel to provide continuing medical education and to promote implementation of innovations or translate new knowledge to change practice within healthcare systems. Previous reviews have concluded that educational meetings can result in small changes in behaviour, but that effects vary considerably. Investigations into which characteristics of educational meetings might lead to greater impact have yielded varying results, and factors that might explain heterogeneity in effects remain unclear. This is the second update of this Cochrane Review.

OBJECTIVES

• To assess the effects of educational meetings on professional practice and healthcare outcomes • To investigate factors that might explain the heterogeneity of these effects SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, ERIC, Science Citation Index Expanded (ISI Web of Knowledge), and Social Sciences Citation Index (last search in November 2016).

SELECTION CRITERIA

We sought randomised trials examining the effects of educational meetings on professional practice and patient outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. One review author assessed the certainty of evidence (GRADE) and discussed with a second review author. We included studies in the primary analysis that reported baseline data and that we judged to be at low or unclear risk of bias. For each comparison of dichotomous outcomes, we measured treatment effect as risk difference adjusted for baseline compliance. We expressed adjusted risk difference values as percentages, and we noted that values greater than zero favour educational meetings. For continuous outcomes, we measured treatment effect as per cent change relative to the control group mean post test, adjusted for baseline performance; we expressed values as percentages and noted that values greater than zero favour educational meetings. We report means and 95% confidence intervals (CIs) and, when appropriate, medians and interquartile ranges to facilitate comparisons to previous versions of this review. We analysed professional and patient outcomes separately and analysed 22 variables that were hypothesised a priori to explain heterogeneity. We explored heterogeneity by using univariate meta-regression and by inspecting violin plots.

MAIN RESULTS

We included 215 studies involving more than 28,167 health professionals, including 142 new studies for this update. Educational meetings as the single intervention or the main component of a multi-faceted intervention compared with no intervention • Probably slightly improve compliance with desired practice when compared with no intervention (65 comparisons, 7868 health professionals for dichotomous outcomes (adjusted risk difference 6.79%, 95% CI 6.62% to 6.97%; median 4.00%; interquartile range 0.29% to 13.00%); 28 comparisons, 2577 health professionals for continuous outcomes (adjusted relative percentage change 44.36%, 95% CI 41.98% to 46.75%; median 20.00%; interquartile range 6.00% to 65.00%)) • Probably slightly improve patient outcomes compared with no intervention (15 comparisons, 2530 health professionals for dichotomous outcomes (adjusted risk difference 3.30%, 95% CI 3.10% to 3.51%; median 0.10%; interquartile range 0.00% to 4.00%); 28 comparisons, 2294 health professionals for continuous outcomes (adjusted relative percentage change 8.35%, 95% CI 7.46% to 9.24%; median 2.00%; interquartile range -1.00% to 21.00%)) The certainty of evidence for this comparison is moderate. Educational meetings alone compared with other interventions • May improve compliance with desired practice when compared with other interventions (6 studies, 1402 health professionals for dichotomous outcomes (adjusted risk difference 9.99%, 95% CI 9.47% to 10.52%; median 16.5%; interquartile range 0.80% to 16.50%); 2 studies, 72 health professionals for continuous outcomes (adjusted relative percentage change 12.00%, 95% CI 9.16% to 14.84%; median 12.00%; interquartile range 0.00% to 24.00%)) No studies met the inclusion criteria for patient outcome measurements. The certainty of evidence for this comparison is low. Interactive educational meetings compared with didactic (lecture-based) educational meetings • We are uncertain of effects on compliance with desired practice (3 studies, 370 health professionals for dichotomous outcomes; 1 study, 192 health professionals for continuous outcomes) or on patient outcomes (1 study, 54 health professionals for continuous outcomes), as the certainty of evidence is very low Any other comparison of different formats and durations of educational meetings • We are uncertain of effects on compliance with desired practice (1 study, 19 health professionals for dichotomous outcomes; 1 study, 20 health professionals for continuous outcomes) or on patient outcomes (1 study, 113 health professionals for continuous outcomes), as the certainty of evidence is very low. Factors that might explain heterogeneity of effects Meta-regression suggests that larger estimates of effect are associated with studies judged to be at high risk of bias, with studies that had unit of analysis errors, and with studies in which the unit of analysis was the provider rather than the patient. Improved compliance with desired practice may be associated with: shorter meetings; poor baseline compliance; better attendance; shorter follow-up; professionals provided with additional take-home material; explicit building of educational meetings on theory; targeting of low- versus high-complexity behaviours; targeting of outcomes with high versus low importance; goal of increasing rather than decreasing behaviour; teaching by opinion leaders; and use of didactic versus interactive teaching methods. Pre-specified exploratory analyses of behaviour change techniques suggest that improved compliance with desired practice may be associated with use of a greater number of behaviour change techniques; goal-setting; provision of feedback; provision for social comparison; and provision for social support. Compliance may be decreased by the use of follow-up prompts, skills training, and barrier identification techniques.

AUTHORS' CONCLUSIONS

Compared with no intervention, educational meetings as the main component of an intervention probably slightly improve professional practice and, to a lesser extent, patient outcomes. Educational meetings may improve compliance with desired practice to a greater extent than other kinds of behaviour change interventions, such as text messages, fees, or office systems. Our findings suggest that multi-strategy approaches might positively influence the effects of educational meetings. Additional trials of educational meetings compared with no intervention are unlikely to change the review findings; therefore we will not further update this review comparison in the future. However, we note that randomised trials comparing different types of education are needed.

Improving Care Management in Attention-Deficit/Hyperactivity Disorder: An RCT

OBJECTIVES

To compare the effectiveness of care management combined with a patient portal versus a portal alone for communication among children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Randomized controlled trial conducted at 11 primary care practices. Children aged 5 to 12 years old with ADHD were randomly assigned to care management + portal or portal alone. The portal included parent-reported treatment preferences and goals, medication side effects, and parent- and teacher-reported ADHD symptom scales. Care managers provided education to families; communicated quarterly with parents, teachers, and clinicians; and coordinated care. The main outcome, changes in the Vanderbilt Parent Rating Scale (VPRS) score as a measure of ADHD symptoms, was assessed using intention-to-treat analysis.

RESULTS

A total of 303 eligible children (69% male; 46% Black) were randomly assigned, and 273 (90%) completed the study. During the 9-month study, parents in the care management + portal arm communicated inconsistently with care managers (mean 2.2; range 0-6) but similarly used the portal (mean 2.3 vs 2.2) as parents in the portal alone arm. In multivariate models, VPRS scores decreased over time (Adjusted β = -.015; 95% confidence interval -0.023 to -0.07) in both groups, but there were no intervention-by-time effects (Adjusted β = .000; 95% confidence interval -0.011 to 0.012) between groups. Children who received ≥2 care management sessions had greater reductions in VPRS scores than those with fewer sessions.

CONCLUSIONS

Results did not provide evidence that care management combined with a patient portal was different from portal use alone among children with ADHD. Both groups demonstrated similar reductions in ADHD symptoms. Those families with greater care management engagement demonstrated greater reductions than those with less engagement.

Psychotropic Medication Prescribing in Primary Care: Pediatric Chief Resident Perspectives

OBJECTIVE

Evidence-based treatments for mental health concerns include psychopharmacological and psychosocial approaches. Pediatrics organizations indicate psychopharmacology needs to be a component of training. This study investigated the status of training in psychotropic medication prescribing through a national survey of pediatric chief residents.

METHOD

Pediatric chief residents (one per residency program) completed a survey (response rate = 60.2%, 127/211) about their attitudes, knowledge, comfort, practice, and training around prescribing psychotropic medication in primary care. Quantitative data included descriptive statistics and correlational analyses to explore relationships between variables; qualitative data were examined through classical content analysis.

RESULTS

Almost half of respondents reported prescribing sometimes or often. Frequency of prescribing varied by mental health condition, with highest frequency for attention-deficit/hyperactivity disorder. About two-thirds of respondents reported having at least some/average knowledge. About half of respondents reported being uncomfortable with prescribing; respondents were most uncomfortable with prescribing antianxiety, mood stabilizing, and antipsychotic medications, and with discontinuing medication; about half indicated their competence in progress-monitoring needed improvement. Concurrent psychosocial treatment was perceived as very useful, although often inaccessible to patients. Prescribing frequency was related to knowledge, comfort, progress-monitoring competence, and training quality; training quality was related to knowledge and comfort. Over 60% rated their training as not at all or only somewhat adequate.

CONCLUSIONS

Pediatric chief residents reported having knowledge of psychotropic medication issues, but experience a general discomfort, especially with discontinuing medication, and with medications other than stimulants. Most thought their training needed improvement in terms of comprehensiveness and clinical practice experiences.

Factors Associated with Parental Treatment Attitudes and Information-Seeking Behaviors for Childhood ADHD

Objective: Despite the association between childhood ADHD and long-term negative outcomes, there is a significant delay to treatment and a low rate of lifetime treatment contact for individuals with ADHD. Method: The current study examined (a) variables associated with parental treatment-seeking attitudes and information-seeking behaviors and (b) the relationship between these attitudes and behaviors in 87 non-treatment-seeking parents whose children had elevated ADHD symptoms. Results: Regressions indicated that attitudes toward ADHD treatment were associated with ADHD knowledge and misconceptions (ps < .01), susceptibility to ADHD stigma (p < .001), and satisfaction with past providers (ps < .01). Experience with past providers was significantly associated with information-seeking behavior (ps < .01). Conclusion: Parental knowledge of ADHD, low levels of stigma, and positive experiences with past providers were the strongest predictors of positive attitudes about ADHD treatment. Experience with past providers was the only factor related to treatment-seeking behavior. These results offer avenues to decreasing barriers to treatment in pediatric ADHD.

Measurement-Based Care in the Treatment of Attention-Deficit/Hyperactivity Disorder and Disruptive Behavior Disorders

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood psychiatric diagnoses. The core symptoms of ADHD include inattention, impulsivity, and hyperactivity. ADHD entails impairments that have extensive and profound detrimental effects on many critical developmental areas. As a valid neurobiologic condition that causes significant impairments in those affected, it is one of the best-researched disorders in medicine. Measurement-based care in treatment of ADHD is critical in establishing a diagnosis, determining a treatment target, and assessing treatment response. This article highlights the rationale for measurement-based care in ADHD, how to implement measurement-based care in clinical practice, and common challenges encountered.

Value-Driven Care in Developmental-Behavioral Pediatrics, Part 2: Measuring Quality and Meeting the Challenge

The drive to improve quality and reduce cost of health care is leading to a value-driven transformation of the US health care landscape. This is the second of a 2-part series on value-driven care and its implications for developmental-behavioral pediatrics (DBP). Part 1 addressed costs of care and enhancing value of care, with a particular focus on the value proposition of the field of DBP. This study begins with a discussion of the Donabedian's model of quality, including structure, process, patient satisfaction, and outcomes. The challenges of measuring process and outcomes in DBP are discussed, with a focus on (1) children 0 to 3 years of age identified as having global developmental delay, (2) recent diagnosis of complex attention-deficit hyperactivity disorder (ADHD) (ADHD plus comorbid conditions), and (3) children with autism spectrum disorder (ASD) and disruptive behavior. The study concludes with some of the important next steps for DBP providers, researchers, health care systems, professional societies, and families. With a discussion of national trends and a local example of a DBP program's response to these trends, the series is intended to provoke discussion and action in the field, contribute to the demonstration of value of a DBP approach to care, and help to chart a course toward growth and sustainability of DBP in an era of value-based care.

Comparison of Performance on ADHD Quality of Care Indicators: Practitioner Self-Report Versus Chart Review

Objective: This study compared practitioner self-report of ADHD quality of care measures with actual performance, as documented by chart review. Method: In total, 188 practitioners from 50 pediatric practices completed questionnaires in which they self-reported estimates of ADHD quality of care indicators. A total of 1,599 charts were reviewed. Results: The percentage of patients for whom practitioners self-reported that they used evidence-based care was higher in every performance category when compared with chart review, including higher use of parent and teacher rating scales during assessment and treatment compared with chart review. Self-reported use of Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) criteria during assessment was also higher than by chart review. The actual number of days until the first contact after starting medication was nearly three times longer than self-report estimates. Conclusion: Practitioners overreport performance on quality of care indicators. These differences were large and consistent across ADHD diagnostic and treatment monitoring practices. Practitioner self-report of ADHD guideline adherence should not be considered a valid measure of performance.

Leveraging Providers' Preferences to Customize Instructional Content in Information and Communications Technology-Based Training Interventions: Retrospective Analysis of a Mobile Phone-Based Intervention in India

Background

Many public health programs and interventions across the world increasingly rely on using information and communications technology (ICT) tools to train and sensitize health professionals. However, the effects of such programs on provider knowledge, practice, and patient health outcomes have been inconsistent. One of the reasons for the varied effectiveness of these programs is the low and varying levels of provider engagement, which, in turn, could be because of the form and mode of content used. Tailoring instructional content could improve engagement, but it is expensive and logistically demanding to do so with traditional training

Objective

This study aimed to discover preferences among providers on the form (articles or videos), mode (featuring peers or experts), and length (short or long) of the instructional content; to quantify the extent to which differences in these preferences can explain variation in provider engagement with ICT-based training interventions; and to compare the power of content preferences to explain provider engagement against that of demographic variables.

Methods

We used data from a mobile phone–based intervention focused on improving tuberculosis diagnostic practices among 24,949 private providers from 5 specialties and 1734 cities over 1 year. Engagement time was used as the primary outcome to assess provider engagement. K-means clustering was used to segment providers based on the proportion of engagement time spent on content formats, modes, and lengths to discover their content preferences. The identified clusters were used to predict engagement time using a linear regression model. Subsequently, we compared the accuracy of the cluster-based prediction model with one based on demographic variables of providers (eg, specialty and geographic location).

Results

The average engagement time across all providers was 7.5 min (median 0, IQR 0-1.58). A total of 69.75% (17,401/24,949) of providers did not consume any content. The average engagement time for providers with nonzero engagement time was 24.8 min (median 4.9, IQR 2.2-10.1). We identified 4 clusters of providers with distinct preferences for form, mode, and length of content. These clusters explained a substantially higher proportion of the variation in engagement time compared with demographic variables (32.9% vs 1.0%) and yielded a more accurate prediction for the engagement time (root mean square error: 4.29 vs 5.21 and mean absolute error: 3.30 vs 4.26).

Conclusions

Providers participating in a mobile phone–based digital campaign have inherent preferences for instructional content. Targeting providers based on individual content preferences could result in higher provider engagement as compared to targeting providers based on demographic variables.

ADHD Diagnosis and Treatment Guidelines: A Historical Perspective

Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral condition and the second most common chronic illness in children. The observance of specific behaviors in multiple settings have remained the most successful method for diagnosing the condition, and although there are differences in specific areas of the brain, and a high heritability estimate (∼76%), they are not diagnostically specific. Medications, and particularly stimulant medication, have undergone rigorous studies to document their efficacy dating back to the 1970s. Likewise, behavioral interventions in the form of parent training and classroom programs have demonstrated robust efficacy during the same time period. Both medication and behavioral interventions are symptomatic treatments. The availability of only symptomatic treatments places ADHD in the same category as other chronic conditions such as diabetes and asthma. Successful treatment of most individuals requires ongoing adherence to the therapy. Improved communication between patients and their families, primary and mental health providers, and school personnel is necessary for effective ADHD treatment. Further enhancement of electronic systems to facilitate family, school, and provider communication can improve monitoring of ADHD symptoms and functional performance. The American Academy of Pediatrics ADHD guidelines were initially developed to help primary care clinicians address the needs of their patients with ADHD and were further refined with the second revision in 2019.

Using Participatory Design Methodologies to Co-Design and Culturally Adapt the Spanish Version of the Mental Health eClinic: Qualitative Study

Background

The Mental Health eClinic (MHeC) aims to deliver best-practice clinical services to young people experiencing mental health problems by making clinical care accessible, affordable, and available to young people whenever and wherever they need it most. The original MHeC consists of home page with a visible triage system for those requiring urgent help; a online physical and mental health self-report assessment; a results dashboard; a booking and videoconferencing system; and the generation of a personalized well-being plan. Populations who do not speak English and reside in English-speaking countries are less likely to receive mental health care. In Australia, international students have been identified as disadvantaged compared with their peers; have weaker social support networks; and have higher rates of psychological distress. This scenario is acquiring significant relevance as Spanish-speaking migration is rapidly growing in Australia, and the mental health services for culturally and linguistically diverse populations are limited. Having a Spanish version (MHeC-S) of the Mental Health eClinic would greatly benefit these students.

Objective

We used participatory design methodologies with users (young people aged 16-30 years, supportive others, and health professionals) to (1) conduct workshops with users to co-design and culturally adapt the MHeC; (2) inform the development of the MHeC-S alpha prototype; (3) test the usability of the MHeC-S alpha prototype; (4) translate, culturally adapt, and face-validate the MHeC-S self-report assessment; and (5) collect information to inform its beta prototype.

Methods

A research and development cycle included several participatory design phases: co-design workshops; knowledge translation; language translation and cultural adaptation; and rapid prototyping and user testing of the MHeC-S alpha prototype.

Results

We held 2 co-design workshops with 17 users (10 young people, 7 health professionals). A total of 15 participated in the one-on-one user testing sessions (7 young people, 5 health professionals, 3 supportive others). We collected 225 source documents, and thematic analysis resulted in 5 main themes (help-seeking barriers, technology platform, functionality, content, and user interface). A random sample of 106 source documents analyzed by 2 independent raters revealed almost perfect agreement for functionality (kappa=.86; P<.001) and content (kappa=.92; P<.001) and substantial agreement for the user interface (kappa=.785; P<.001). In this random sample, no annotations were coded for help-seeking barriers or the technology platform. Language was identified as the main barrier to getting medical or psychological services, and smartphones were the most-used device to access the internet. Acceptability was adequate for the prototype’s 5 main elements: home page and triage system, self-report assessment, dashboard of results, booking and video visit system, and personalized well-being plan. The data also revealed gaps in the alpha prototype, such as the need for tailored assessment tools and a greater integration with Spanish-speaking services and communities. Spanish-language apps and e-tools, as well as online mental health information, were lacking.

Conclusions

Through a research and development process, we co-designed and culturally adapted, developed and user tested, and evaluated the MHeC-S. By translating and culturally adapting the MHeC to Spanish, we aimed to increase accessibility and availability of e-mental health care in the developing world, and assist vulnerable populations that have migrated to English-speaking countries.

Online Digital Education for Postregistration Training of Medical Doctors: Systematic Review by the Digital Health Education Collaboration

Background

Globally, online and local area network–based (LAN) digital education (ODE) has grown in popularity. Blended learning is used by ODE along with traditional learning. Studies have shown the increasing potential of these technologies in training medical doctors; however, the evidence for its effectiveness and cost-effectiveness is unclear.

Objective

This systematic review evaluated the effectiveness of online and LAN-based ODE in improving practicing medical doctors’ knowledge, skills, attitude, satisfaction (primary outcomes), practice or behavior change, patient outcomes, and cost-effectiveness (secondary outcomes).

Methods

We searched seven electronic databased for randomized controlled trials, cluster-randomized trials, and quasi-randomized trials from January 1990 to March 2017. Two review authors independently extracted data and assessed the risk of bias. We have presented the findings narratively. We mainly compared ODE with self-directed/face-to-face learning and blended learning with self-directed/face-to-face learning.

Results

A total of 93 studies (N=16,895) were included, of which 76 compared ODE (including blended) and self-directed/face-to-face learning. Overall, the effect of ODE (including blended) on postintervention knowledge, skills, attitude, satisfaction, practice or behavior change, and patient outcomes was inconsistent and ranged mostly from no difference between the groups to higher postintervention score in the intervention group (small to large effect size, very low to low quality evidence). Twenty-one studies reported higher knowledge scores (small to large effect size and very low quality) for the intervention, while 20 studies reported no difference in knowledge between the groups. Seven studies reported higher skill score in the intervention (large effect size and low quality), while 13 studies reported no difference in the skill scores between the groups. One study reported a higher attitude score for the intervention (very low quality), while four studies reported no difference in the attitude score between the groups. Four studies reported higher postintervention physician satisfaction with the intervention (large effect size and low quality), while six studies reported no difference in satisfaction between the groups. Eight studies reported higher postintervention practice or behavior change for the ODE group (small to moderate effect size and low quality), while five studies reported no difference in practice or behavior change between the groups. One study reported higher improvement in patient outcome, while three others reported no difference in patient outcome between the groups. None of the included studies reported any unintended/adverse effects or cost-effectiveness of the interventions.

Conclusions

Empiric evidence showed that ODE and blended learning may be equivalent to self-directed/face-to-face learning for training practicing physicians. Few other studies demonstrated that ODE and blended learning may significantly improve learning outcomes compared to self-directed/face-to-face learning. The quality of the evidence in these studies was found to be very low for knowledge. Further high-quality randomized controlled trials are required to confirm these findings.

Sharing of ADHD Information between Parents and Teachers Using an EHR-Linked Application

BACKGROUND

Appropriate management of attention-deficit/hyperactivity disorder (ADHD) involves parents, clinicians, and teachers. Fragmentation of interventions between different settings can lead to suboptimal care and outcomes. Electronic systems can bridge gaps across settings. Our institution developed an email-based software to collect ADHD information from parents and teachers, which delivered data directly to the clinician within the electronic health record (EHR).

OBJECTIVE

We sought to adapt our institution's existing EHR-linked system for ADHD symptom monitoring to support communication between parents and teachers and then to assess child characteristics associated with sharing of ADHD information.

METHODS

We updated our software to support automated sharing of ADHD information between parents and teachers. Sharing was optional for parents but obligatory for teachers. We conducted a retrospective cohort study involving 590 patients at 31 primary care sites to evaluate a system for sharing of ADHD-specific health information between parents and teachers. We used multivariable logistic regression to estimate associations between child characteristics and parental sharing. We further investigated the association between child characteristics and viewing of survey results delivered through the electronic communication system.

RESULTS

Most parents (64%) elected to share survey results with teachers at the first opportunity and the vast majority (80%) elected to share all possible information. Parents who elected to share usually continue sharing at subsequent opportunities (89%). Younger child age and performance impairments were associated with increased likelihood of sharing. However, parents viewed only 16% of teacher submitted surveys and teachers only viewed 30% of surveys shared by parents.

CONCLUSION

This study demonstrates that electronic systems to capture ADHD information from parents and teachers can be adapted to support communication between them, and that parents are amenable to sharing ADHD information with teachers. However, strategies are needed to encourage viewing of shared information.

A Learning Collaborative Approach to Improve Mental Health Service Delivery in Pediatric Primary Care

Supplemental Digital Content is available in the text.

Background:

Pediatric primary care practitioners (PPCPs) report inadequate training in the care of children with common mental health conditions. Although additional training is needed, system changes are also necessary to support improvements in care.

Methods:

We developed the Building Mental Wellness Learning Collaborative to assist PPCPs in delivering better mental health services in primary care by targeting 5 focus areas: mental health promotion; early identification and screening; practitioner skills; collaboration and community linkages; and medication management. Aims were developed for each area.

Results:

Twenty-one practices and 50 practitioners completed the collaborative in 2 seven-month waves. For mental health promotion, ≥85% of charts showed documentation in 3 of 4 preselected areas. For early identification/screening, screening increased, but the ≥85% goal was not met. For practitioner skills, a ≥20% increase in the proportion of children/youth ≥1 visits for anxiety or depression was achieved, from 0.70% of children/youth in the 12 months preintervention to 1.09% children/youth in the 12 months after. For collaboration/linkages, mental health referral completion was unchanged and below the 60% goal. For medication use, a ≥15% increase in selective serotonin reuptake inhibitor prescribing by Building Mental Wellness (BMW) practitioners was achieved from 0.72% children/youth with office visits pre-BMW to 0.92% post. Prescribing did not decrease for atypical antipsychotic medication use or for psychotropic medication use in children younger than 6 years, although there was a trend toward more appropriate prescribing.

Conclusions:

The BMW Learning Collaborative was effective in helping PPCPs implement certain aspects of a comprehensive approach to the delivery of mental health services in primary care.

The acceptability and feasibility of emailed parent questionnaires for medical and developmental surveillance after NICU discharge

OBJECTIVES

The following are the objectives of this study: (1) Assess the feasibility and acceptability of emailing parent-reported measures of infant health and development after NICU discharge. (2) Examine whether post-discharge questionnaire data helps identify infants most likely to benefit from specialized follow-up care.

STUDY DESIGN

Parents of 51 infants <32 weeks' gestation received email questionnaires at 44 weeks postmenstrual age (PMA) and 6 months corrected age (CA). Adverse infant outcomes were assessed in-person at 6 months: (1) Bayley-III cognitive or motor score <85; (2) weight, length, or head circumference <10th percentile; (3) new referral for medical or developmental services.

RESULTS

Questionnaire response was 48 (94%) at 44 weeks PMA and 46 (90%) at 6 months CA. 36 (70%) infants were assessed at 6 months; 72% had at least 1 adverse outcome. Poorer transition home, feeding problems, and special health care needs at 44 weeks PMA predicted adverse outcomes. Feeding problems, maternal depression, and lower infant health-related quality of life at 6 months CA correlated with adverse outcomes.

CONCLUSIONS

Emailed questionnaires after NICU discharge were feasible to implement and acceptable to families. Repeated post-discharge assessments may help identify infants at heightened health and developmental risk.

Role of mHealth in overcoming the occurrence of post-stroke depression

Depression associated with stroke affects roughly one-third of stroke survivors. Post-stroke depression (PSD) is thought to adversely influence functional outcome by limiting participation in rehabilitation, decreasing physical, social, and cognitive function, and affecting neuroplasticity thereby placing stroke survivors at high risk for future vascular events. PSD has also been associated with higher mortality rates after stroke. In Peru, a country where there is no national stroke program and mental health disorders are largely underdiagnosed and untreated, people with PSD are likely to be further challenged by dependency and impoverished conditions that will limit their use of ambulatory services, leading to inadequate clinical follow-up. In this scenario, mobile health (mHealth) technology offers a promising approach to extend access to high-quality and culturally tailored evidence-based psychological care to address PSD given that cell phone use, Internet connectivity, and digital health technology have met a rapid growth in the last years and thus contribute to the attainment of broader Sustainable Development Goals (SDGs). The limited evidence of the effectiveness of mHealth for PSD calls for researchers to fill a knowledge gap where Peru poses as an ideal setting because rapid expansion of digital technology and current mental healthcare reform could be leveraged to enhance post-stroke outcomes. This article proposes the rationale for a suitable evidence-driven, mHealth-based, PSD self-management intervention called iMOODS-Investigating the role of mHealth in overcoming occurrence of depression after stroke-that could be tested among recent stroke patients with PSD in resource constrained settings.

Distance-Learning, ADHD Quality Improvement in Primary Care: A Cluster-Randomized Trial

OBJECTIVE

To evaluate a distance-learning, quality improvement intervention to improve pediatric primary care provider use of attention-deficit/hyperactivity disorder (ADHD) rating scales.

METHODS

Primary care practices were cluster randomized to a 3-part distance-learning, quality improvement intervention (web-based education, collaborative consultation with ADHD experts, and performance feedback reports/calls), qualifying for Maintenance of Certification (MOC) Part IV credit, or wait-list control. We compared changes relative to a baseline period in rating scale use by study arm using logistic regression clustered by practice (primary analysis) and examined effect modification by level of clinician participation. An electronic health record-linked system for gathering ADHD rating scales from parents and teachers was implemented before the intervention period at all sites. Rating scale use was ascertained by manual chart review.

RESULTS

One hundred five clinicians at 19 sites participated. Differences between arms were not significant. From the baseline to intervention period and after implementation of the electronic system, clinicians in both study arms were significantly more likely to administer and receive parent and teacher rating scales. Among intervention clinicians, those who participated in at least 1 feedback call or qualified for MOC credit were more likely to give parents rating scales with differences of 14.2 (95% confidence interval [CI], 0.6-27.7) and 18.8 (95% CI, 1.9-35.7) percentage points, respectively.

CONCLUSION

A 3-part clinician-focused distance-learning, quality improvement intervention did not improve rating scale use. Complementary strategies that support workflows and more fully engage clinicians may be needed to bolster care. Electronic systems that gather rating scales may help achieve this goal. Index terms: ADHD, primary care, quality improvement, clinical decision support.

Quality improvement, implementation, and dissemination strategies to improve mental health care for children and adolescents: a systematic review

BACKGROUND

Some outcomes for children with mental health problems remain suboptimal because of poor access to care and the failure of systems and providers to adopt established quality improvement strategies and interventions with proven effectiveness. This review had three goals: (1) assess the effectiveness of quality improvement, implementation, and dissemination strategies intended to improve the mental health care of children and adolescents; (2) examine harms associated with these strategies; and (3) determine whether effectiveness or harms differ for subgroups based on system, organizational, practitioner, or patient characteristics.

METHODS

Sources included MEDLINE®, the Cochrane Library, PsycINFO, and CINAHL, from database inception through February 17, 2017. Additional sources included gray literature, additional studies from reference lists, and technical experts. Two reviewers selected relevant randomized controlled trials (RCTs) and observational studies, extracted data, and assessed risk of bias. Dual analysis, synthesis, and grading of the strength of evidence for each outcome followed for studies meeting inclusion criteria. We also used qualitative comparative analysis to examine relationships between combinations of strategy components and improvements in outcomes.

RESULTS

We identified 18 strategies described in 19 studies. Eleven strategies significantly improved at least one measure of intermediate outcomes, final health outcomes, or resource use. Moderate strength of evidence (from one RCT) supported using provider financial incentives such as pay for performance to improve the competence with which practitioners can implement evidence-based practices (EBPs). We found inconsistent evidence involving strategies with educational meetings, materials, and outreach; programs appeared to be successful in combination with reminders or providing practitioners with newly collected clinical information. We also found low strength of evidence for no benefit for initiatives that included only educational materials or meetings (or both), or only educational materials and outreach components. Evidence was insufficient to draw conclusions on harms and moderators of interventions.

CONCLUSIONS

Several strategies can improve both intermediate and final health outcomes and resource use. This complex and heterogeneous body of evidence does not permit us to have a high degree of confidence about the efficacy of any one strategy because we generally found only a single study testing each strategy.

TRIAL REGISTRATION

PROSPERO, CRD42015024759 .

Specific Components of Pediatricians' Medication-Related Care Predict Attention-Deficit/Hyperactivity Disorder Symptom Improvement

OBJECTIVE

The development of attention-deficit/hyperactivity disorder (ADHD) care quality measurements is a prerequisite to improving the quality of community-based pediatric care of children with ADHD. Unfortunately, the evidence base for existing ADHD care quality metrics is poor. The objective of this study was to identify which components of ADHD care best predict patient outcomes.

METHOD

Parents of 372 medication-naïve children in grades 1 to 5 presenting to their community-based pediatrician (N = 195) for an ADHD-related concern and who were subsequently prescribed ADHD medication were identified. Parents completed the Vanderbilt ADHD Parent Rating Scale (VAPRS) at the time ADHD was raised as a concern and then approximately 12 months after starting ADHD medication. Each patient's chart was reviewed to measure 12 different components of ADHD care.

RESULTS

Across all children, the mean decrease in VAPRS total symptom score during the first year of treatment was 11.6 (standard deviation 10.1). Of the 12 components of ADHD care, shorter times to first contact and more teacher ratings collected in the first year of treatment significantly predicted greater decreases in patient total symptom scores. Notably, it was timeliness of contacts, defined as office visits, phone calls, or email communication, that predicted more ADHD symptom decreases. Office visits alone, in terms of number or timeliness, did not predict patient outcomes.

CONCLUSION

The magnitude of ADHD symptom decrease that can be achieved with the use of ADHD medications was associated with specific components of ADHD care. Future development and modifications of ADHD quality care metrics should include these ADHD care components.

Impact of Mental Health Comorbidities on the Community-Based Pediatric Treatment and Outcomes of Children with Attention Deficit Hyperactivity Disorder

OBJECTIVE

Children with attention deficit hyperactivity disorder (ADHD) often exhibit psychiatric comorbidities, which may impact illness presentation, diagnosis, and treatment outcomes. Guidelines exist for dealing with these complex cases but little is known about how comorbidities are being handled in community pediatric settings. The purpose of this study was to evaluate how mental health comorbidities affect community physicians' ADHD care practices and patients' symptom trajectories.

METHOD

Medical charts of 319 children presenting at primary care clinics for ADHD-related concerns were reviewed. Physician assessment and treatment behaviors were extracted and parents rated ADHD symptoms at the time of diagnosis and at 3, 6, and 12 months. Baseline ratings were used to group children, as no comorbid mental health condition, internalizing, or externalizing comorbid condition. Multilevel analyses compared community physician care behaviors and ADHD symptom trajectories across groups.

RESULTS

Approximately, 50 percent of the sample met screening criteria for a comorbid mental health condition. For children diagnosed with ADHD and treated with medication, community physician care largely did not differ across groups, but children with internalizing comorbidities made significantly smaller improvements in inattentive and hyperactive/impulsive symptoms compared with children with no comorbidities.

CONCLUSION

Children with ADHD and mental health comorbidities, particularly internalizing disorders, exhibit less robust response to ADHD medication and may require additional testing before starting medication and/or alternative treatment approaches. Potential barriers to conducting comprehensive assessments and to providing multi-modal treatment are discussed.

Information and Communication Technologies for the Dissemination of Clinical Practice Guidelines to Health Professionals: A Systematic Review

BACKGROUND

The transfer of research knowledge into clinical practice can be a continuous challenge for researchers. Information and communication technologies, such as websites and email, have emerged as popular tools for the dissemination of evidence to health professionals.

OBJECTIVE

The objective of this systematic review was to identify research on health professionals' perceived usability and practice behavior change of information and communication technologies for the dissemination of clinical practice guidelines.

METHODS

We used a systematic approach to retrieve and extract data about relevant studies. We identified 2248 citations, of which 21 studies met criteria for inclusion; 20 studies were randomized controlled trials, and 1 was a controlled clinical trial. The following information and communication technologies were evaluated: websites (5 studies), computer software (3 studies), Web-based workshops (2 studies), computerized decision support systems (2 studies), electronic educational game (1 study), email (2 studies), and multifaceted interventions that consisted of at least one information and communication technology component (6 studies).

RESULTS

Website studies demonstrated significant improvements in perceived usefulness and perceived ease of use, but not for knowledge, reducing barriers, and intention to use clinical practice guidelines. Computer software studies demonstrated significant improvements in perceived usefulness, but not for knowledge and skills. Web-based workshop and email studies demonstrated significant improvements in knowledge, perceived usefulness, and skills. An electronic educational game intervention demonstrated a significant improvement from baseline in knowledge after 12 and 24 weeks. Computerized decision support system studies demonstrated variable findings for improvement in skills. Multifaceted interventions demonstrated significant improvements in beliefs about capabilities, perceived usefulness, and intention to use clinical practice guidelines, but variable findings for improvements in skills. Most multifaceted studies demonstrated significant improvements in knowledge.

CONCLUSIONS

The findings suggest that health professionals' perceived usability and practice behavior change vary by type of information and communication technology. Heterogeneity and the paucity of properly conducted studies did not allow for a clear comparison between studies and a conclusion on the effectiveness of information and communication technologies as a knowledge translation strategy for the dissemination of clinical practice guidelines.

School-based Screening to Identify Children At Risk for Attention-Deficit/Hyperactivity Disorder: Barriers and Implications

This report describes a school-based screening project to improve early identification of children at risk for attention-deficit/hyperactivity disorder (ADHD) and communicate these concerns to parents, recommending that they contact their child's primary care provider (PCP). Of 17,440 eligible children in first through fifth grades in five school districts, 47.0% of parents provided required written consent, and teachers completed 70.4% of the online screeners (using the Vanderbilt AD/HD Diagnostic Teacher Rating Scale). Of 5,772 screeners completed, 18.1% of children (n = 1,044) were identified as at risk. Parents of at-risk children were contacted to explain risk status and recommended to visit their child's PCP for further evaluation. It was not possible to contact 39.1% of parents of at-risk children. Of the 636 parents of at-risk children who could be contacted, 53.1% (n = 338) verbally accepted the recommendation to follow-up with their PCP, which was not related to ADHD symptom severity. Parents of children with IEPs or related services were more likely to accept the recommendation to visit the PCP. Our exploration of the potential for school-based screening for ADHD identified a number of barriers to successful execution, but the data also indicated that this is an important problem to address.

Current State and Model for Development of Technology-Based Care for Attention Deficit Hyperactivity Disorder

INTRODUCTION

Care (i.e., evaluation and intervention) delivered through technology is used in many areas of mental health services, including for persons with attention deficit hyperactivity disorder (ADHD). Technology can facilitate care for individuals with ADHD, their parents, and their care providers. The adoption of technological tools for ADHD care requires evidence-based studies to support the transition from development to integration into use in the home, school, or work for persons with the disorder. The initial phase, which is development of technological tools, has begun in earnest; however, the evidence base for many of these tools is lacking. In some instances, the uptake of a piece of technology into home use or clinical practice may be further along than the research to support its use.

METHODS

In this study, we review the current evidence regarding technology for ADHD and also propose a model to evaluate the support for other tools that have yet to be tested.

RESULTS

We propose using the Research Domain Criteria as a framework for evaluating the tools' relationships to dimensions related to ADHD.

CONCLUSION

This article concludes with recommendations for testing new tools that may have promise in improving the evaluation or treatment of persons with ADHD.

Impact of a Web-Portal Intervention on Community ADHD Care and Outcomes

BACKGROUND

The quality of care for children with attention-deficit/hyperactivity disorder (ADHD) delivered in community-based pediatric settings is often poor. Interventions have been developed to improve community-based ADHD care but have not demonstrated that better care results in improved patient outcomes. The objective of this study was to determine whether an ADHD quality improvement (QI) intervention for community-based pediatric practices improves patient outcomes.

METHODS

A cluster randomized controlled trial was conducted in which 50 community-based pediatric primary care practices (213 providers) were randomized either to receive a technology-assisted QI intervention or to a control condition. The intervention consisted of 4 training sessions, office flow modification, guided QI, and an ADHD Internet portal to assist with treatment monitoring. ADHD treatment processes and parent- and teacher-rated ADHD symptoms over the first year of treatment were collected for 577 patients.

RESULTS

Intent-to-treat analyses examining outcomes of all children assessed for ADHD were not significant (b = -1.97, P = .08). However, among the 373 children prescribed ADHD medication, there was a significant intervention effect (b = -2.42, P = .04) indicating greater reductions in parent ratings of ADHD symptoms after treatment among patients treated by intervention physicians compared with patients treated at control practices. There were no group differences on teacher ratings of ADHD symptoms. ADHD treatment care around medication was significantly better at intervention practices compared with control practices.

CONCLUSIONS

A technology-assisted QI intervention improved some ADHD care quality and resulted in additional reductions in parent-rated ADHD symptoms among patients prescribed ADHD medications.

Relationship Between Attention-Deficit/Hyperactivity Disorder Care and Medication Continuity

OBJECTIVE

To describe the relationships between attention-deficit/hyperactivity disorder (ADHD) care practices and subsequent medication use.

METHOD

A retrospective cohort from a random sample of medical records in 50 pediatric practices with 188 providers, including 1,352 children who started ADHD medication, was studied. Independent variables included physician behaviors related to medication titration and monitoring of treatment response. Primary outcomes were number of days covered with ADHD medication during the first year of treatment and time from starting medicine to the first 30-day gap in medication supply. Multilevel modeling and Cox proportional hazards regression models were conducted.

RESULTS

Children had an average medication supply of 217 days in the first year. Half experienced a 30-day gap in medication supply in the first 3 months. Nearly three-fourths had a medication adjustment in the first year with the first adjustment usually being a dosage change. The average time to the first medication adjustment was over 3 months. Physician's first contact with parents occurred in the first month of treatment for less than half, with the average time being over 2 months. Little variation related to ADHD care quality was accounted for at the physician level. Early titration and early contact were related to greater medication supply and continuity of treatment.

CONCLUSION

Earlier physician-delivered ADHD care (e.g., contact with parent after starting medication and medication adjustment) is related to greater medication supply and continuity. It remains to be determined whether interventions that improve the quality of titration and monitoring practices for children with ADHD would also improve medication continuity.

Diagnosis of attention-deficit/hyperactivity disorder by developmental pediatricians in academic centers: A DBPNet study

OBJECTIVE

To describe the developmental-behavioral pediatricians (DBPs), patients, and clinical practices used in the diagnostic assessments of attention-deficit/hyperactivity disorder (ADHD) within all 12 academic medical centers comprising Developmental-Behavioral Pediatrics Research Network (DBPNet).

METHODS

Between December 2011 and June 2012, all DBPs who evaluated children with ADHD or autism spectrum disorders were asked to complete a diagnostic encounter survey form for up to 10 consecutive new cases that resulted in the diagnosis of ADHD or autism spectrum disorder. Fifty-two clinicians returned one or more forms for children diagnosed with ADHD (n = 211).

RESULTS

DBPs were generally experienced full-time academics. Children were 76.3% male, 62.3% white, 24.5% African American, and 20.7% Hispanic. Mean child age was 8.0 + 3.1 years. DBPs reviewed parent ratings of behavior in 84.4% and teacher ratings in 69.2% of cases. They reviewed or completed at least one developmental assessment in 79.2% of cases: intelligence (60.2%), academic (57.8%), fine motor or visual motor (39.3%), speech/language (34.6%), or adaptive skills (28.9%). They made the diagnosis of coexisting conditions in 82.7% of cases, including learning disabilities (31.8%), speech/language disorders (31.8%), anxiety (14.2%), externalizing disorders (10.9%), and sleep disorders (9.5%). Among 146 children not medicated before the visit, stimulant medications were initiated in 15 children (10.2%).

CONCLUSIONS

Within DBPNet, DBPs were highly likely to complete comprehensive assessments of ADHD that went beyond the requirements of primary care practice guidelines. They typically identified coexisting developmental and learning conditions. They did not typically prescribe medication at the end of diagnostic encounters.

Growth of Secure Messaging Through a Patient Portal as a Form of Outpatient Interaction across Clinical Specialties

OBJECTIVE

Patient portals are online applications that allow patients to interact with healthcare organizations. Portal adoption is increasing, and secure messaging between patients and healthcare providers is an emerging form of outpatient interaction. Research about portals and messaging has focused on medical specialties. We characterized adoption of secure messaging and the contribution of messaging to outpatient interactions across diverse clinical specialties after broad portal deployment.

METHODS

This retrospective cohort study at Vanderbilt University Medical Center examined use of patient-initiated secure messages and clinic visits in the three years following full deployment of a patient portal across adult and pediatric specialties. We measured the proportion of outpatient interactions (i.e., messages plus clinic visits) conducted through secure messaging by specialty over time. Generalized estimating equations measured the likelihood of message-based versus clinic outpatient interaction across clinical specialties.

RESULTS

Over the study period, 2,422,114 clinic visits occurred, and 82,159 unique portal users initiated 948,428 messages to 1,924 recipients. Medicine participated in the most message exchanges (742,454 messages; 78.3% of all messages sent), followed by surgery (84,001; 8.9%) and obstetrics/gynecology (53,424; 5.6%). The proportion of outpatient interaction through messaging increased from 12.9% in 2008 to 33.0% in 2009 and 39.8% in 2010 (p<0.001). Medicine had the highest proportion of outpatient interaction conducted through messaging in 2008 (23.3% of outpatient interactions in medicine). By 2010, this proportion was highest for obstetrics/gynecology (83.4%), dermatology (71.6%), and medicine (56.7%). Growth in likelihood of message-based interaction was greater for anesthesiology, dermatology, obstetrics/gynecology, pediatrics, and psychiatry than for medicine (p<0.001).

CONCLUSIONS

This study demonstrates rapid adoption of secure messaging across diverse clinical specialties, with messaging interactions exceeding face-to-face clinic visits for some specialties. As patient portal and secure messaging adoption increase beyond medicine and primary care, research is needed to understand the implications for provider workload and patient care.

Variability in ADHD care in community-based pediatrics

BACKGROUND

Although many efforts have been made to improve the quality of care delivered to children with attention-deficit/hyperactivity disorder (ADHD) in community-based pediatric settings, little is known about typical ADHD care in these settings other than rates garnered through pediatrician self-report.

METHODS

Rates of evidence-based ADHD care and sources of variability (practice-level, pediatrician-level, patient-level) were determined by chart reviews of a random sample of 1594 patient charts across 188 pediatricians at 50 different practices. In addition, the associations of Medicaid-status and practice setting (ie, urban, suburban, and rural) with the quality of ADHD care were examined.

RESULTS

Parent- and teacher-rating scales were used during ADHD assessment with approximately half of patients. The use of Diagnostic and Statistical Manual of Mental Disorders criteria was documented in 70.4% of patients. The vast majority (93.4%) of patients with ADHD were receiving medication and only 13.0% were receiving psychosocial treatment. Parent- and teacher-ratings were rarely collected to monitor treatment response or side effects. Further, fewer than half (47.4%) of children prescribed medication had contact with their pediatrician within the first month of prescribing. Most variability in pediatrician-delivered ADHD care was accounted for at the patient level; however, pediatricians and practices also accounted for significant variability on specific ADHD care behaviors.

CONCLUSIONS

There is great need to improve the quality of ADHD care received by children in community-based pediatric settings. Improvements will likely require systematic interventions at the practice and policy levels to promote change.

Pharmacotherapy for incident attention-deficit/hyperactivity disorder: practice patterns and quality metrics

INTRODUCTION

This study examines incident treatment patterns for attention-deficit/hyperactivity disorder (ADHD) in children seen in eight integrated healthcare delivery systems and identifies factors associated with adherence to Healthcare Effectiveness Data and Information Set (HEDIS) quality measures developed by the National Committee for Quality Assurance (NCQA).

METHOD

A retrospective cohort analysis using electronic healthcare data from children aged 3 through 17 years with newly diagnosed ADHD between January 1, 2009 and December 31, 2010 was conducted. NCQA quality definitions for initiation and for continuation and maintenance (C&M) of ADHD medications were expanded to include preschoolers and adolescents. Poisson regression models with robust error variance were used to evaluate the association between NCQA HEDIS adherence measures, provider type, patient characteristics and care process measures.

RESULTS

Of 6864 children aged 3-17 years old qualifying for incident treatment analyses, 5538 (80.7%) were started on ADHD medication within a year of diagnosis. Adherence to NCQA HEDIS measures was 49.8% for initiation and 45.8% for C&M, with adherence rates higher for mental health than non-mental health providers, school-aged children than adolescents, and for patients concurrently on other psychotropic medications than those who were not. Of those started on ADHD medication, 62.3% were not eligible for C&M analyses according to HEDIS guidelines, because they did not receive continuous (210 of 300 days) ADHD medication treatment, with adolescents less likely than school-aged children to persist with medications.

CONCLUSION

Study limitations must be considered, including reliance on electronic medical record data, absence of patient race and sociodemographic data, and limited generalizability to other care contexts. Nevertheless, findings suggest novel strategies are needed to improve the quality of ADHD care processes for children of all ages, because even within integrated delivery systems less than half of children with ADHD received care consistent with NCQA HEDIS standards for initiation and C&M care. RESULTS suggest the need to refine quality measures by including follow-up care in those children not receiving or discontinuing medication treatment, a considerable quality concern not currently captured in NCQA HEDIS standards.

Understanding the acceptability of a computer decision support system in pediatric primary care

OBJECTIVE

Individual users' attitudes and opinions help predict successful adoption of health information technology (HIT) into practice; however, little is known about pediatric users' acceptance of HIT for medical decision-making at the point of care.

MATERIALS AND METHODS

We wished to examine the attitudes and opinions of pediatric users' toward the Child Health Improvement through Computer Automation (CHICA) system, a computer decision support system linked to an electronic health record in four community pediatric clinics. Surveys were administered in 2011 and 2012 to all users to measure CHICA's acceptability and users' satisfaction with it. Free text comments were analyzed for themes to understand areas of potential technical refinement.

RESULTS

70 participants completed the survey in 2011 (100% response rate) and 64 of 66 (97% response rate) in 2012. Initially, satisfaction with CHICA was mixed. In general, users felt the system held promise; however various critiques reflected difficulties understanding integrated technical aspects of how CHICA worked, as well as concern with the format and wording on generated forms for families and users. In the subsequent year, users' ratings reflected improved satisfaction and acceptance. Comments also reflected a deeper understanding of the system's logic, often accompanied by suggestions on potential refinements to make CHICA more useful at the point of care.

CONCLUSIONS

Pediatric users appreciate the system's automation and enhancements that allow relevant and meaningful clinical data to be accessible at point of care. Understanding users' acceptability and satisfaction is critical for ongoing refinement of HIT to ensure successful adoption into practice.

Strategies of adherence promotion in the management of pediatric chronic conditions

Children and families often have difficulty following prescribed medical treatment for chronic pediatric conditions. Such nonadherence has a significant impact on children's health care outcomes and the costs of their care. This review describes a comprehensive approach to increase treatment adherence in chronic pediatric illnesses and lessen its impact. Key elements of this proposed model of adherence promotion include the following: (1) a core approach to adherence promotion to be implemented by pediatric health care providers; (2) follow-up and ongoing management; and (3) tailoring and targeting specific more intensive family-centered interventions to children and adolescents who demonstrate clinically significant treatment nonadherence or risk for nonadherence. Behavioral specialists have important roles in conducting research on adherence promotion, training health care providers, and delivering services to children and adolescents with clinically significant adherence problems.

Healthcare reform, quality, and technology: ADHD as a case study

The concepts of healthcare reform and population health are shifting the emphasis from traditional, volume-based care to a model in which value, or quality, predominates. High quality care will be increasingly rewarded, with financial consequences for poor performance. This shift will be accelerated by the use of healthcare technology, a rapidly growing industry with tools ranging from electronic health records to smart phones and web portals. In this article we highlight pertinent legislative reforms followed by a review of technologies that may play a role in the implementation of these reforms. Pediatric Attention Deficit Hyperactivity Disorder is used as an example given the large number of proposed tools for this condition. While the evidence base is weak for some technologies, research regarding web portals is better developed and will be presented as an example of a technology that may allow practitioners and organizations to improve healthcare quality in several dimensions.

Clinical considerations for the management of pediatric patients with attention-deficit/hyperactivity disorder

Introduction: Attention-deficit/hyperactivity disorder (ADHD) is a chronic health condition presenting with symptoms of hyperactivity, impulsivity, and/or inattention in early childhood, adolescence and adulthood. Many patients will persist with associated symptoms throughout their life and may require long term treatment to maintain adequate control.

Objective: The purpose of this article is to review the current literature in regards to diagnosis, treatment, and management of ADHD in the pediatric and adolescent population.

Methods: A search was conducted using PubMed, Medline, Ovid, and CINHAL with a focus on studies and reviews in the English language from 2008 – 2013, featuring pediatric/adolescent patients across the ages of 4–17 years using the terms: “management”, “attention-deficit”, “hyperactivity”, and “treatment.” Literature referenced prior to the five-year time frame outlined herein provided foundational information on diagnostics and medications.

Discussion: Stimulants, in conjunction with behavioral therapy, are standard first line treatments used in ADHD. While stimulant medications have been shown to be effective in treating symptoms associated with ADHD, there are a variety of concerns that may prevent their use. These concerns are related to adverse consequences, many of which are not supported by concrete evidence. Other pharmacotherapy options such as norepinephrine reuptake inhibitors and selective alpha-2 adrenergic agonists are typically reserved as second line options. The use of novel and emerging complementary therapies will also be explored.

Conclusion: Patients diagnosed with ADHD must be thoroughly evaluated when making decisions regarding treatment. Many studies and reviews support the efficacy of pharmacotherapy in treatment of ADHD; however, there is insufficient evidence regarding long-term safety of the medications. Further research is warranted to evaluate current treatment options and associated risks and benefits to guide the clinician in optimal management of these patients.

The myADHDportal.com Improvement Program: An innovative quality improvement intervention for improving the quality of ADHD care among community-based pediatricians

Though the American Academy of Pediatrics has developed and disseminated clear evidence-based guidelines for ADHD care, community-based pediatricians often have difficulty implementing these guidelines. New strategies are needed to improve the quality of care received by children with ADHD and to improve utilization of the AAP consensus guidelines by pediatricians. An evidence-based quality improvement intervention has been developed that effectively improves the quality of ADHD care delivered by community-based pediatricians. In order to facilitative widespread dissemination of this intervention model, the entire intervention has been modified for online delivery. The intervention is called the myADHDportal.com Improvement Program. The full functionality of this online intervention is described including the collection of online ADHD rating scales from parents and teachers and online communication between parents, teachers, and physicians. In addition, the web portal integrates several innovative quality improvement features including an online wizard for mapping ADHD patient flow, an online report card for monitoring quality of care, and an online wizard for guiding practices through the Plan-Do-Study-Act (PDSA) cycle process. The combination of clinical utility and quality improvement tools facilitates delivery of quality ADHD care and reduces several of the obstacles to implementing AAP-recommended practice behaviors. Initial results with this intervention model are reviewed and goals for dissemination are described.

Evaluating the promise of health IT to enhance/expand the reach of mental health services

OBJECTIVE

A growing number of health information technologies (HIT) are being developed and tested to address mental health conditions. HIT includes Internet and smartphone programs or apps, text messaging protocols and telepsychiatry. We reviewed the promise and evidence that HIT can expand access to mental health care and reduce disparities in use of services across groups in need.

CONCLUSIONS

Limited reach of mental health services is a pervasive problem in the United States, and solving it will require innovations that enable us to extend our clinical reach into underserved populations without significantly expanding our workforce. In theory, HIT can extend access to mental health care in several ways: by enhancing the reach to priority populations, addressing system capacity issues, supporting training, improving clinical decision making, lowering the "consumer's threshold" for treatment, delivering preventive mental health services, speeding innovation and adoption and reducing cost barriers to treatment. At present, evidence is limited, and research is needed, focusing on consumer engagement strategies, the benefits and harms of HIT for the therapeutic relationship and the comparative effectiveness of various HIT alternatives.

Does long-term medication use improve the academic outcomes of youth with attention-deficit/hyperactivity disorder?

Youth with Attention-Deficit/Hyperactivity Disorder (ADHD) frequently experience academic impairment, including lower grades than their peers and elevated risk for grade retention and school dropout. Medication is the most commonly used treatment for youth with ADHD, and it is therefore essential to understand the extent to which medication use improves long-term academic functioning. This paper reviews the literature on the relation between long-term medication use and the academic outcomes of youth with ADHD. A systematic literature search was conducted to identify pertinent studies published since 2000 that followed youth with ADHD for 3 or more years. Academic outcomes of interest included school grades, achievement test scores, and grade retention. Nine studies were identified reporting on eight distinct longitudinal samples (N across studies = 8,721). These studies demonstrate that long-term medication use is associated with improvements in standardized achievement scores. However, the magnitude of these improvements is small and the clinical or educational significance is questionable. Evidence for long-term improvements in school grades and grade retention is less compelling. This review highlights methodological considerations in providing directions for future research. The importance of using multiple sources to gather information about medication adherence is discussed, including use of methodologies such as electronic monitors, rather than relying solely on parent report or chart review. Future research should also examine a range of medication adherence definitions in order to determine whether age of onset, duration of use, dose, and/or consistency of use moderates the relation between long-term medication use and academic outcomes.