ADHD: Opportunities to Enhance Quality of Pediatric Care. Adrian Sandler MD Olson Huff Center Mission Children s Hospital Asheville NC

Transcription

1 ADHD: Opportunities to Enhance Quality of Pediatric Care Adrian Sandler MD Olson Huff Center Mission Children s Hospital Asheville NC

2 Beyond meds - a perspective on effective ADHD care Goals of talk Discuss pharmacotherapy of complex ADHD Consider practice changes to improve quality of care Highlight resources for QI in ADHD care

3 Treatment of ADHD: Keys to Effective Management Thorough diagnostic formulation Medical perspective differential diagnosis Identify strengths, weaknesses, comorbidities Determination of severity Demystification, clarify goals of treatment Individualization of management Flexible multi-modal treatment Rational use of stimulants and other meds

4 Differential diagnosis of the inattentive child: NEEDS An MD N Normal variation - temperament, maturational delay E Expectations unrealistic E Environment/Experience poverty, stress, ACE, trauma D Disability LD, I/DD, ASD S Sleep sleep onset delay, night awakening An Anxiety M Medical iron deficiency, nutrition, seizure disorder, OSA, etc D Depression, mood disorder

5 These are my principles. If you don t like them I have others. -Groucho Marx

6 ADHD Rx: Two decades of progress? MTA - efficacy of stimulants and behavior therapy Non-stimulant medications approved for ADHD Plateau in ADHD Rx , but now >3.5 million US children on ADHD meds ( 28%) Evidence for stimulant misuse/abuse Stimulants do not lead to substance abuse Controversy about sudden cardiac death Leading researchers and thought leaders in pharma industry s pockets

7 Treatment of ADHD Plus Comorbidity (co-occurrence): the rule rather than the exception With ODD 15% Inatt, 70% Combined With conduct disorder 20-50% With anxiety or depression 10-40% With learning disability 20-60% With coordination disorder 20-50% With tic disorders/ocd 10-20% With substance abuse 10-30% of older adolescents With bipolar disorder? Very controversial Functional impairment, treatment priorities and target symptoms

8 Treatment of Complex ADHD ADHD plus Depression or Anxiety disorders Consider which condition is most impairing Usually treat depression first psychotherapy alone or psychotherapy plus SSRI No significant interactions between SSRI and stimulants Anxiety and demoralization may be secondary to ADHD Industry-sponsored trial indicates that atomoxetine may be efficacious in treatment of ADHD plus anxiety Bipolar disorder Coordinated and comprehensive behavioral health care Use of divalproex and other mood stabilizers Low dose stimulant may provide additional benefit

9 Tic disorders, Tourette syndrome (TS) and ADHD Comorbidity with ADHD common ADHD in 10-70% of individuals with TS learning disability in >20% of children with TS? Children with ADHD often have tics MPH in ADHD+tics: the rule of thirds tics may persist, but impairment may be minimal Evaluate scope of comorbid dx -ADHD, OCD, anxiety Single drug versus polypharmacy Start low, go slow with drug titration

10 Treating target symptoms in children with ADHD? Hyperactivity:: Stimulants, clonidine, guanfacine, atomoxetine, amantadine Sleep problems: Melatonin, clonidine, trazodone, atomoxetine Aggression/disruptive behavior: Clonidine, guanfacine, risperidone, carbamazepine, amantadine Anxiety: SSRI, benzodiazepines, buspirone Depressed mood: SSRI Tics: guanfacine, clonidine, risperidone

11 Targeted combined therapy or Pharmacodesperation! Thanks for the referral. I ve started him on fluoxetine for his compulsive behavior, clonidine for his tics, risperidone for his aggression, trazodone to help him sleep, and 25 mg imipramine for old time s sake.

12 Polypharmacy in children In 2005, 1.6 million children and teenagers (280,000 <10 years old) prescribed at least two psychoactive drugs in combination More than 500,000 prescribed at least three psychoactive medications together More than 160,000 prescribed four medications together! Medco Health Solutions, 2006

13 How to avoid pharmacodesperation A primary care medical home Care coordination Judicious use of consultants Continual effort to simplify regimen Psychoeducation Acceptance and appropriate expectations Maintaining medium and long-term perspective Understanding problematic behaviors

14 Functional behavioral analysis ABCs: antecedents, behaviors, consequences The communicative nature of behavior Common reasons for behavior problems To get attention/what you want/preferred item To get away/escape/avoid non-preferred activity Overstimulation and anxiety/sensory overload Sensation-seeking Response to pain

15 Quality of Care Paradigm Donabedian, 1988 STRUCTURE Physical/organizational attributes of care PROCESS What is actually done and how it is done OUTCOMES Condition-specific, multidimensional - health and quality of life Satisfaction with care

16 We are what we repeatedly do. Excellence then, is not an act, but a habit. Aristotle et al, Proc Plato Acad, 340 BC

17 Quality in Healthcare Doing the right thing, at the right time, in the right way, for the right person and having the best possible results -US Agency for Healthcare Research and Quality Getting each patient to the desired outcome, without harm, without waste, and with an exceptional patient and family experience - Ron Paulus MD, CEO, Mission Health System

18 Adding value in health care? Value = health outcomes achieved/$ spent Value assures sustainability and unites stakeholders Tracking outcomes and costs longitudinally Enhancing efficiency up to a point Standardization CPMs, EHR decision support Innovations in treatments or delivery models

19 Goals and strategies of practice-based QI efforts in ADHD care Chung, Baum, Soares, Chan. JDBP 35, 2014, and Goals Improve access to care Improve accuracy of diagnosis Improve treatment adherence Improve comprehensiveness Improve follow-up care Improve standardization Measurement of outcomes Strategies -Intake/scheduling changes to cut wait lists -Increase use of ADHD scales -Systematic assessment of comorbidities -Increase participation of child/parent -Improve practice-based ADHD education -Refer children<6yrs for behavior Rx first -Increase frequency of follow up visits -Implement care processes across practice -Measure and document outcomes of care

20 SDBP Benchmarks of Quality Survey 2009 survey of SDBP membership Response from 157 members plus input from SIGs Criteria: value, feasibility, evidence-based 30% respondents measuring process of ADHD care >50% routinely measure ADHD symptom severity Barriers to measuring quality systematically Lack of EMR functionality Need for additional documentation and data entry Brief measures of impairment not readily available Physicians skeptical and concerned that outcome measures may fail to measure the care they provide

21 SDBP Metrics of Quality 2009 ADHD Process of Care % New Pt evaluations DSM criteria used in diagnosis % NP evals systematic assessment for comorbidities % NP evals information from parent and teacher obtained % F/up visits for which ht, wt, BP, HR documented ADHD Outcomes of Care % F/up pts assessment of function/target symptoms % F/up pts improved function/target symptoms at 3 mo

22 Clinician-driven enhancement of EHRs: Our experience in Asheville Three measures: ADHD POC, ASD POC and CFIS Measures created 2011/12 Initially built by Cerner Revision and enhancements 2012/13 Slow and frustrating process! Intention to disseminate and make freely available in public domain Unresolved questions re ownership

23 ADHD POC New Pt DSM criteria met? Validated diagnostic tool used? Comorbidity assessed systematically? Patient/Family education provided? Behavioral therapy prescribed first for pts <6 yrs? F/up Pts If 1 st f/u visit, within 45 days of diagnosis? If not 1 st f/u visit, within 6 months of previous visit? Recent symptoms measured with validated tool? If pt on meds, side effects assessed systematically?

24 Clinical Functional Improvement Scale (CFIS) Loosely based on CGIS, but specific (not global) Clinician and caregiver select functional impairment(s)/target symptom(s) from list For each, contributory source data selected Severity rated on 5 point Likert scale For pts seen in f/u, interval change recorded on 7 point Likert scale

25 Compensation and quality measures: Our experience in Asheville MMA Comp incentives for quality and pt satisfaction Quality incentive 3% in 2013, 4% in 2014 Quality metrics, targets determined annually by specialty group, reviewed by Comp Committee DB Peds quality goals 2014 Children 5-12 yrs, NP evals, primary dx ADHD, validated DSM-based tool (such as Vanderbilt) and DSM criteria met. Goal 90% Children , NP evals, primary dx ADHD, referred for behavior therapy first (before prescribing medication). Goal 60%

26 CHIPRA PQMP ADHD Expert Work Group Accurate ADHD Diagnosis pts 4-18 years Confirm functional impairment in >1 setting Assess core symptoms using DSM-based tool or direct assessment of the patient Behavior Therapy as first-line Treatment for Preschool Age Evidence-based behavior therapy prior to meds Both measures based on med record data Reliability of such measures low-moderate Review process laborious and costly www/ahrq.gov/chipra

27 Using admin data to measure quality? We got a long way to go. HEDIS (Healthcare Effectiveness Data and Information Set) has only one ADHD process measure Denominator: kids 6-12 on med >210 days Numerator: 1 visit within 30 d of initiation and 2 or more visits between 4 weeks and 9 months

28 What makes a good measure? How strong is the scientific evidence supporting the validity as a quality measure? Are all individuals in the denominator equally eligible for inclusion in the numerator? Is the measure result under the control of those whom the measure evaluates? How well do the measure specifications capture the event that is the subject of the measure? Does the measure provide for fair comparisons of the performance of providers, facilities, health plans of geographic areas?

29 Obtaining credit for MOC through ABP American Board of Pediatrics ADHD Diagnosis PIM and Follow-up PIM each offers 20 MOC Part 4 pts plus 20 hours of Cat I CME Cincinnati Children s myadhdportal.com offers 25 MOC Part 4 pts plus 20 hrs CME

30 Opportunities for Quality Improvement in ADHD Treatment Providing family support and education Referring for evidence-based behavior therapy Appropriate titration of medication dose Measurement and monitoring of HR, BP, Wt, Ht Target symptom identification and measurement Timeliness of follow up Collection of parent and teacher rating scales Reduction of target symptoms/functional impairment Avoidance of polypharmacy Cost containment, e.g., use of generics