Community-wide Intervention to Improve the Attention-Deficit/Hyperactivity Disorder Assessment and Treatment Practices of Community Physicians

Epstein, Jeffery N.; Langberg, Joshua M.; Lichtenstein, Philip; Mainwaring, Beth A.; Luzader, Carolyn P.; Stark, Lori J.

doi:10.1542/peds.2007-2704

Cited by 75 publications

(98 citation statements)

References 21 publications

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“…3,19 In previous investigations of this intervention model using practice-selected charts, we reported higher baseline levels of practice behaviors. 5,11 The present study's use of randomly selected patient charts, as opposed to physician self-reports or practice-selected patient charts, produced dramatically lower rates of evidence-based practice behaviors (ie, 14%-20% used teacher rating scales during assessments). The discrepancies between these different data collection modalities are considerable and should be considered in interpretation of the results of studies that use selfreports or reviews of nonrandomly selected charts.…”

Section: Discussionmentioning

confidence: 69%

“…The low rates of evidence-based ADHD treatment practices have repeatedly been found to be resistant to reliable implementation. 5,7 Additional intervention components (eg, community collaborations 20 or assignment of case managers [21][22][23] ) might possibly help parents and teachers to improve adherence to prescribed practices.…”

Section: Discussionmentioning

confidence: 99%

“…1,2 Despite widespread efforts to promote physician awareness of these guidelines, AAPrecommended practice behaviors are not being implemented reliably. [3][4][5][6] Several attempts to develop interventions to improve physicians' use of evidencebased, ADHD-related practice behaviors have been reported. 5,[7][8][9][10] In the most comprehensive of those interventions, Epstein et al 5 conducted a community-wide intervention to train 202 physicians from 55 practices.…”

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confidence: 99%

“…The intervention focused on improving the assessment and treatment practices of community providers by using didactic and quality improvement methods. In an open-label study of the intervention's effectiveness, Epstein et al 5 demonstrated significant improvements in a number of AAPrecommended practice behaviors at 1 year after the intervention. Intervention gains were maintained at 2 years after the intervention.…”

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confidence: 99%

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Use of an Internet Portal to Improve Community-Based Pediatric ADHD Care: A Cluster Randomized Trial

et al. 2011

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WHAT'S KNOWN ON THIS SUBJECT:Although evidence-based guidelines for pediatric attention-deficit/hyperactivity disorder (ADHD) care exist, adherence to the guidelines in communitybased settings has been problematic. Effective interventions that improve the quality of pediatricians' ADHD care and are ready for widespread dissemination do not currently exist. WHAT THIS STUDY ADDS:By using a cluster-randomized trial design, results of this study provide evidence that a quality improvement intervention that is conducive to widespread dissemination improves the ADHD assessment and treatment behaviors of community-based pediatricians.abstract OBJECTIVE: To determine the effectiveness of a quality improvement program to improve pediatricians' adherence to existing, evidencebased, attention-deficit/hyperactivity disorder (ADHD) practice guidelines. METHODS: Forty-nine community-based pediatricians at 8 practices participated in a cluster-randomized trial. Practices were matched according to the numbers of pediatricians and the proportions of patients receiving Medicaid. The medical charts for a random sample of patients with ADHD for each of the participating pediatricians were examined at baseline and 6 months. All practices participated in 4 sessions of training, including didactic lectures and office flow modification workshops. Practices were then given access to an ADHD Internet portal that allowed parents, teachers, and pediatricians to input information (eg, rating scales) about patients, after which information was scored, interpreted, and formatted in a report style that was helpful for assessment and treatment of patients with ADHD. Physicians evaluated their practice behaviors quarterly and addressed underperforming areas. RESULTS: Pediatricians in the intervention group, compared with those in the control group, demonstrated significantly higher rates of many American Academy of Pediatrics-recommended ADHD care practices, including collection of parent (Cohen's d ϭ 0.69) and teacher (d ϭ 0.68) rating scales for assessment of children with ADHD, use of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria (d ϭ 0.85), and use of teacher rating scales to monitor treatment responses (d ϭ 1.01). CONCLUSION: A quality improvement intervention that can be widely disseminated by using Internet-based information technology significantly improved the quality of ADHD care in community-based pediatric settings.

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Section: Discussionmentioning

confidence: 69%

Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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Use of an Internet Portal to Improve Community-Based Pediatric ADHD Care: A Cluster Randomized Trial

et al. 2011

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“…Recent models for enhancing mental health services in primary care [1][2][3][4] include outside psychiatric assessment and telephone consultation, 5 collaborative peer consultation, [6][7][8] mental health assessment skills training, 9 and collaborative care interventions. 10,11 As suggested in a recent review, these studies have revealed progress in improving provider care processes (eg, medication for attention-deficit/hyperactivity disorder [ADHD]; mental health assessment) and child symptoms (eg, ADHD, depression), but also call for larger and more rigorous trials.…”

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confidence: 99%

Collaborative Care Outcomes for Pediatric Behavioral Health Problems: A Cluster Randomized Trial

Kolko¹,

et al. 2014

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WHAT'S KNOWN ON THIS SUBJECT: Integrated or collaborative care intervention models have revealed gains in provider care processes and outcomes in adult, child, and adolescent populations with mental health disorders. However optimistic, conclusions are not definitive due to methodologic limitations and a dearth of studies. WHAT THIS STUDY ADDS:This randomized trial provides further evidence for the efficacy of an on-site intervention (Doctor Office Collaborative Care) coordinated by care managers for children' s behavior problems. The findings provide support for integrated behavioral health care using novel provider and caregiver outcomes.abstract OBJECTIVE: To assess the efficacy of collaborative care for behavior problems, attention-deficit/hyperactivity disorder (ADHD), and anxiety in pediatric primary care (Doctor Office Collaborative Care; DOCC). METHODS:Children and their caregivers participated from 8 pediatric practices that were cluster randomized to DOCC (n = 160) or enhanced usual care (EUC; n = 161). In DOCC, a care manager delivered a personalized, evidence-based intervention. EUC patients received psychoeducation and a facilitated specialty care referral. Care processes measures were collected after the 6-month intervention period. Family outcome measures included the Vanderbilt ADHD Diagnostic Parent Rating Scale, Parenting Stress Index-Short Form, Individualized Goal Attainment Ratings, and Clinical Global Impression-Improvement Scale. Most measures were collected at baseline, and 6-, 12-, and 18-month assessments. Provider outcome measures examined perceived treatment change, efficacy, and obstacles, and practice climate.RESULTS: DOCC (versus EUC) was associated with higher rates of treatment initiation (99.4% vs 54.2%; P , .001) and completion (76.6% vs 11.6%, P , .001), improvement in behavior problems, hyperactivity, and internalizing problems (P , .05 to .01), and parental stress (P , .05-.001), remission in behavior and internalizing problems (P , .01, .05), goal improvement (P , .05 to .001), treatment response (P , .05), and consumer satisfaction (P , .05). DOCC pediatricians reported greater perceived practice change, efficacy, and skill use to treat ADHD (P , .05 to .01).CONCLUSIONS: Implementing a collaborative care intervention for behavior problems in community pediatric practices is feasible and broadly effective, supporting the utility of integrated behavioral health care services. Pediatrics 2014;133:e981-e992

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Attention-Deficit/Hyperactivity Disorder Outcomes for Children Treated in Community-Based Pediatric Settings

Epstein¹,

Langberg²,

Lichtenstein³

et al. 2010

Arch Pediatr Adolesc Med

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To determine if children treated by community physicians who participated in an attention-deficit/ hyperactivity disorder (ADHD) quality improvement intervention demonstrate symptom and impairment improvements comparable with those achieved in university-based clinical trials. Design: Case series. Setting: Rural, suburban, and urban practices, with 28% of the 47 practices serving primarily (Ͼ50% of patients) Medicaid-receiving populations. Participants: A total of 785 children aged between 7 and 11 years were treated for ADHD by community physicians participating in the study. Intervention: A total of 158 community physicians from 47 separate practices participated in a quality improvement intervention, the ADHD Collaborative, designed to improve physician adherence to evidence-based ADHD treatment guidelines. The intervention included mapping and redesign of practice office flow to facilitate adherence to American Academy of Pediatrics ADHD guidelines as well as didactic sessions related to diagnosis and treatment of ADHD. Medical record reviews were completed at the initial assessment and every 3 months for 1 year to evaluate treatment outcome. Outcome Measures: Improvement in parent-and teacherrated ADHD symptoms and functional impairment. Results: Children showed large improvements in parent-and teacher-rated ADHD symptoms, similar to some clinical trials, but made no significant improvements in functional impairment. Conclusions: Large improvements in ADHD symptoms can be achieved in primary care settings when physicians provide evidence-based ADHD care using medication. Because many children with ADHD continued to have significant functional impairment despite symptom improvement, collaboration with other mental health or educational services in additional to medication appears warranted.

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Community-wide Intervention to Improve the Attention-Deficit/Hyperactivity Disorder Assessment and Treatment Practices of Community Physicians

Cited by 75 publications

References 21 publications

Use of an Internet Portal to Improve Community-Based Pediatric ADHD Care: A Cluster Randomized Trial

Use of an Internet Portal to Improve Community-Based Pediatric ADHD Care: A Cluster Randomized Trial

Collaborative Care Outcomes for Pediatric Behavioral Health Problems: A Cluster Randomized Trial

Attention-Deficit/Hyperactivity Disorder Outcomes for Children Treated in Community-Based Pediatric Settings

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