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

Abstract

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.

Keywords::

• Adherence
• Attention-deficit hyperactivity disorder
• Persistence
• Quality measurement
• Stimulant
• Treatment patterns

Transparency

Declaration of funding

This project was supported by grant number 1R01HS019912 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality or the Department of Health and Human Services. K.J.N. and M.F.D. had full access to all of the data in this study and take responsibility for the integrity of the data and the accuracy of the data analyses.

Declaration of financial/other relationships

R.B. has disclosed that she has received funding from Otsuka, Pfizer, Medice and Janssen-Cilag, all unrelated to the current study. L.J.H. has disclosed that she has received funding from Proctor and Gamble, Centocor, Genentech, Roch, Medimmune, and Pfizer, all unrelated to the current study. K.J.N., A.G.W., D.A.N., L.D., J.A.B., S.T., P.P., J.D.N., D.M., and M.F.D. have disclosed that they have no significant relationships with or financial interests in any commercial companies related to this study or article.

CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

The authors thank the programmers, analysts, and research specialists from the following SPAN sites for providing data for this project: Group Health Research Institute (GHRI), Harvard Pilgrim Health Care Institute (HPHCI), HealthPartners Institute for Education and Research (HPIER), Kaiser Permanente Hawaii (KPHI), Kaiser Permanente Northern California (KPNC), Kaiser Permanente Northwest (KPNW), Kaiser Permanente Georgia (KPGA), and Kaiser Permanente Colorado (KPCO). We are indebted to the following SPAN investigators for the collaborations that made this study possible: GHRI (Denise Boudreau PhD RPh), KPGA (Melissa Butler PharmD PhD), and KPHI (Cynthia Nakasato MD). The authors also thank David C. Tabano MS, Andrew T. Sterrett PhD, Lisa Pieper MSHA MBA, Sophia R. Newcomer MPH, Jennifer Dickman-Portz MSW PhD, Barbara McCray, and Michael Shainline MS, for their helpful technical and administrative assistance.