Variability in ADHD care in community-based pediatrics

Abstract

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.

Keywords: attention deficit and disruptive behavior disorders; behavioral medicine; guidelines; pediatrics; quality.

Copyright © 2014 by the American Academy of Pediatrics.

Figures

FIGURE 1

Timeline representing mean durations (with SEs) until first, second, and third treatment contacts and obtaining parent and teacher ratings after medication initiation.

FIGURE 2

Graphical depiction of significant interaction between proportion of patients receiving Medicaid and academic affiliation on rates of receiving psychosocial treatment. For purposes of illustration, the proportion of patients receiving Medicaid was centered to illustrate how practices with an average proportion of Medicaid patients (44.6%; coded 0 on the x-axis of graph) compares with practices with 1 SD fewer Medicaid patients (30.5%; coded −1 on x-axis of graph) and to practices with 1 SD more Medicaid patients (58.7%; coded 1 on x-axis of graph).