Comparative effectiveness research for two medical home models for attention deficit hyperactivity disorder
Grantee: Boston Medical Center
Principal Investigator: Michael Silverstein
Project Number: R40MC17181
Project Date: 2/1/2010
Final Report
Age group(s)
- Middle Childhood (6-11 years)
Abstract
Attention Deficit Hyperactivity Disorder (ADHD), a chronic condition affecting 8-12% of US schoolaged children, is associated with poor academic achievement. Randomized studies have demonstrated the efficacy of a variety of treatment modalities for ADHD; as a result, consensus has emerged across professional societies regarding best practices for diagnosing and treating it. However, approaches to ADHD in primary care settings, where the majority of patients are treated, generally do not conform to this evidence base. Furthermore, among low-income and minority children, ADHD is less likely to be diagnosed correctly or treated successfully than it is among more affluent or white populations. Numerous reports have documented three common reasons for treatment failure among low-income children with ADHD: 1) such families often experience difficulty adhering to treatment plans; 2) parents of children with ADHD have disproportionately high rates of mental illness, which interferes with ADHD self-management; and 3) low-income children with ADHD experience high rates of comorbid illness, particularly oppositional defiant disorder (ODD) and learning disabilities, which can complicate diagnoses or make ADHD more refractory to treatment. Therefore, congruent with the comparative effectiveness research agenda recently outlined by the Institute of Medicine, we propose a randomized study to compare the effectiveness of two care models on ADHD outcomes: one, a model of basic care management and structured communication with specialists, consistent with conventional descriptions of a patient-centered Medical Home (conventional Medical Home arm); and another, which combines the Medical Home with theory-based care management strategies to address common reasons for ADHD treatment failure (enhanced Medical Home arm). Based on the Chronic Care Model, the structure of both intervention arms is a collaborative care system - designed to overcome systems-based barriers to quality care - which aligns primary care clinicians with care managers; and pairs this expanded primary care team with consultant specialists for decision support. We hypothesize, however, that among low-income populations, linking improved care processes to improved outcomes requires additional patient-focused intervention to address specific reasons for treatment failure. Thus, care managers in the enhanced arm will use evidence-based motivational techniques to help parents resolve ambivalence to starting or continuing treatment. Through a paradigm of screening, brief intervention and referral, enhanced care managers will address maternal depression, parental ADHD, and prevalent ADHD comorbidities. Specifically, these care managers will be trained in motivational interviewing, a counseling style with evidence for medication adherence; problem solving therapy, an empowerment technique effective for adult depression; and parent management therapy, an evidence-based approach to managing ODD. A three-site, parallel group RCT (n=140) will compare the effectiveness of two care models on the following measures, which will be collected through in-person interviews using valid and reliable instruments, and through extraction of data from an electronic health record shared by each study site: 1. Provider adherence to ADHD treatment guidelines, and patient adherence to ADHD medication; 2. Referral patterns to specialty care, and time to symptom improvement; and 3. Patient ADHD symptoms and socials skills, 6 and 12 months after diagnosis. The IOM in its 2009 report, National Priorities for Comparative Effectiveness Research - ranked comparing the effectiveness of primary care strategies for childhood ADHD as a top tier priority for a national comparative effectiveness research agenda. We will compare the effectiveness of two care models on ADHD outcomes - the more intensive, designed specifically to address common reasons for ADHD treatment failures pertinent to disadvantaged populations. This study responds to MCHB's Strategic Issue 3, Services and Systems to Assure Quality of Care; and its goal to improve childhood mental health outcomes contributes to a key focus area of the Healthy People 2010 initiative.<< Previous Next >>