Physician Adherence to Guidelines for ADHD Varies Widely
WASHINGTON — It appears that there is a wide range of adherence to the American Academy of Pediatrics guidelines on attention-deficit hyperactivity disorder, Wendy Davis, M.D., said at the annual meeting of the Pediatric Academic Societies.
“While [physicians] show a high level of confidence in prescribing and monitoring stimulant medications … few [physicians] in our study practiced in a manner that reflected understanding and documented use of targeted outcomes. Furthermore, our physicians expressed a lack of confidence in their ability to diagnose and treat attention-deficit hyperactivity coexisting conditions,” said Dr. Davis, a professor of pediatrics at the University of Vermont in Burlington.
In 2000, the AAP released clinical practice guidelines for the diagnosis and evaluation of the child with attention-deficit hyperactivity disorder (ADHD). Dr. Davis and her colleagues evaluated a group of pediatricians in Vermont for their adherence to the following selected recommendations from the guidelines:
▸ The clinician should recommend stimulant medication or behavior therapy as appropriate to improve targeted outcomes.
▸ The physician, parents, child, and school personnel should collaborate to identify targeted outcomes to guide management.
▸ The physician should periodically provide a systematic follow-up for the child with ADHD, and monitoring should be directed to targeted outcomes and adverse effects by obtaining specific information from parents, teachers, and the child.
▸ Evaluation of the child with ADHD should include assessment of possible coexisting conditions.
A total of 22 doctors in five pediatric practices—20% of practicing pediatricians in Vermont—participated. A self-administered pediatrician confidence survey served as a baseline measure. In this survey, pediatricians were asked to rate their confidence with various aspects of the diagnosis and treatment of ADHD.
In addition, a preintervention chart audit was conducted to assess adherence to AAP guidelines on several measures. The initial chart review included charts for all 5- to 15-year-old patients with a diagnosis of ADHD after 2001—a total of 225 (75% male patients).
In the survey, 89% of pediatricians responded that they were mostly or highly confident in starting patients on stimulant medication for the treatment of ADHD.
Based on the preintervention chart audit, 92% of charts indicated stimulants had been prescribed for the treatment of ADHD.
A total of 79% of pediatricians responded that they were mostly or highly confident in adjusting stimulant medication, and 72% of charts had evidence of dosage changes after the initial prescription.
Setting targeted outcomes proved to be more of a challenge for pediatricians, with 58% responding that they were mostly or highly confident in setting these, and 38% of charts had evidence of documented targeted outcomes.
Only 37% of pediatricians were mostly or highly confident in arranging for and coordinating nonpharmacologic treatment of ADHD.
However, 68% indicated that they communicated with school personnel most or almost all of the time.
According to the chart audit, parents were involved in treatment planning and monitoring 85% of the time. In addition, 77% of the charts had evidence of consultation with school personnel.
Based on the chart audit, adverse side effects were evaluated 86% of the time, though only 71% of charts had notations of the duration of effectiveness. Only 39% of charts indicated assessment of the adequacy of medication effectiveness.
Based on the survey, only a third (32%) of pediatricians were mostly or highly confident in identifying coexisting psychiatric conditions. And only 21% were mostly or highly confident in treating ADHD coexisting conditions.
Only 32% of charts had notations of coexisting conditions, Dr. Davis, said at the meeting, also sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.
