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Attention deficit hyperactivity disorder (ADHD) is a commonly occurring behavioral disorder among children, and evidence-based methods for assessment and treatment have been established. Community-based pediatricians are the primary providers of services for children with ADHD; therefore, the American Academy of Pediatrics (AAP) has established guidelines for pediatricians (AAP, 2000, 2001). These guidelines can be challenging to implement in typical community-based practices, and many physicians do not reliably follow the prescribed practice behaviors.
In its ongoing and expansive effort toward quality improvement, Cincinnati Children’s Hospital Medical Center began an ADHD Collaborative in 2004 to train community-based physicians and their office staff to implement the AAP guidelines when assessing and treating their patients with ADHD. The Cincinnati Children’s intervention works with the entire office staff to modify office systems to promote the systematic use of the AAP guidelines across the whole practice. Office physicians are informed about the rationale for implementation of the AAP prescribed guidelines for assessing and treating children with ADHD.
During office flow sessions, pediatric offices work to modify their individual office systems to set up systematic office procedures for collecting ADHD rating scales, deriving written care management plans and monitoring treatment response. For example, physicians and office staff together determine how to ensure the collection of parent and teacher rating scales, decide who in the office will score the scales and how to track follow-up of patients. ADHD Collaborative staff then work with the physicians and office staff to ensure that the new office flow system is implemented effectively, leaving practices with a sustainable model for implementing AAP guidelines. In addition, quality-improvement strategies are used to teach practices how to problem-solve systemic glitches and continually improve the system.
Results of this intervention have been impressive (Epstein et al. 2008). For example, across the project physicians have gone from using parent and teacher rating scales to monitor treatment from 7 percent and 9 percent of the time, respectively, to using the scales 88 percent (parent) and 87 percent (teacher) of the time after exposure to the ADHD Collaborative. These gains have maintained for as long as these offices have been monitored (up to two years; Epstein et al. 2010). Hence, this model seems to have successfully changed pediatrician practices and has maintained sustainability through self-sufficiency.
Spreading the Message
With funding from the National Institute of Mental Health, investigators at Cincinnati Children’s are working on ways to disseminate this intervention to other communities. They recently completed a research study in which pediatricians in Dayton, OH, Jefferson, IN and Lexington and Louisville, KY, were trained to use this intervention through videoconference training and a web portal that allows pediatricians to collect parent and teacher rating scales online. The web portal scores rating scales in real time and provides pediatricians with reports as well as immediate warnings when side effects emerge or behavioral deterioration occurs. The web portal also continually updates information regarding physician practice behavior, thereby allowing pediatricians to view how they are doing in relation to the AAP guidelines. In this study, investigators demonstrated substantial gains in the quality of ADHD care among community-based pediatricians (Epstein et al., in press).
As a way to encourage pediatricians to engage in this quality-improvement intervention, the investigators have received approval as an official American Board of Pediatrics quality-improvement activity, which is now a requirement for pediatricians wishing to renew their licenses. The investigators at Cincinnati Children’s hope to effectively disseminate this intervention to practices across the country.
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