Focus on Quality Improvement in ADHD - MSP …...2011/03/10 · Focus on Quality Improvement in...
Transcript of Focus on Quality Improvement in ADHD - MSP …...2011/03/10 · Focus on Quality Improvement in...
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Focus on Quality Improvement in ADHD
Follow up Care for Children Follow up Care for Children Prescribed ADHD Medication
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Why ADHD?
• Estimates of 11% of school age boys and 4.4% of school age girls have been given a diagnosis of ADD/ ADHD
• Diagnosis increased 3% per year from • Diagnosis increased 3% per year from 1997 to 2006
• Diagnosis is more common in families living below the poverty level
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Why ADHD?
• 6.5% of children with public insurance coverage take medication for ADHD.
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Why ADHD?
• “Annual societal cost of illness” estimated at 36 to 52 billion in 2005 dollars.
• 7million ambulatory care visits in 2006
• Costs include direct ADHD treatment costs • Costs include direct ADHD treatment costs and related health care, education costs, parental work loss and juvenile justice expenses.
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What is the CHIPRA ADHD Indicator?
• Tracking “the percentage of children newly prescribed ADHD medication who have at least three follow-up care visits within a 10-month period, one of which is within 30 10-month period, one of which is within 30 days of when the first ADHD medication was dispensed”.
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What is the CHIPRA ADHD Indicator?
• No ADHD med within the previous 120 days
• Initiation Phase- The percentage of children 6-12 years old with a follow up children 6-12 years old with a follow up visit during the 30 day initiation phase after index prescription start date
• This follow up visit must be face to face.
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What is the CHIPRA ADHD Indicator?
• Continuation and Maintenance Phase-Percentage of children 6-12 years old who remained on the medication for at least 210 days and who had at least 2 follow up 210 days and who had at least 2 follow up visits within 270 days (9 months) after the initiation phase ended. These visits are in addition to the follow up visit during the initiation phase.
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What is the CHIPRA ADHD indicator
• One of the two visits during the Continuation and Maintenance Phase may be a phone follow up with the practitioner
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Concerns with the CHIPRA ADHD indicator
• How are Follow up Visits tracked and documented?
• How can Follow up phone contacts be tracked and documented?tracked and documented?
• Is there solid data supporting the follow up intervals in the ADHD indicator?
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What other Data Can We Evaluate and Incorporate into QI projects
dealing with ADHD?
• Use and documentation of standardized tools in the diagnosis and follow up of ADHD.ADHD.
• AAP toolkit includes Vanderbilt Scales
• Other scales also available
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What Other Data Can We Evaluate and Incorporate into QI Projects?
• Relative Costs of Various Medications for ADHD and Relative Use of These Medications in Practice
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SC Medicaid Data: Percent with Follow-Up Care for Children with ADHD (Ages 6 – 12 Years)
• Initiation
3434 34
35
40
45
50
• Continuation & Maintenance
3234
39 39 39
35
40
45
50
27
25
20
25
20
14
20 20
22
20
23 23
3234
34 34
0
5
10
15
20
25
30
2007 2008 2009 2010
HMO
PCCM
FFS
Benchmark
20
30
2628
16
8
22
25
15
22
25
3234
0
5
10
15
20
25
30
2007 2008 2009 2010
HMO
PCCM
FFS
Benchmark
SC is ranked above the 10th percentile of the HEDIS benchmark.
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AAP Clinical Practice Guideline: Treatment of the School-Aged Child with Attention-
Deficit/Hyperactivity Disorder
• Released Oct 2001
• Targets Children Ages 6 to 12 years
• Clearly recommends stimulant medication and/or behavior therapy largely based and/or behavior therapy largely based upon early MTA study results
• Does not specifically recommend one stimulant over another and states that no specific stimulant has proven superior
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AAP Practice Guideline
• If one stimulant is not effective, guideline recommends trying another stimulant
• Recommends periodic systematic follow up but refrains from recommending a up but refrains from recommending a specific time frame- “No controlled trials clearly document the appropriate frequency of follow-up visits.”
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AAP Practice Guideline
Statement on follow-up frequency- “Once the child is stable, an office visit every 3 to 6 months allows for assessment of learning and behavior.”learning and behavior.”
Follow-up visits should also be used to assess growth, bp, heart rate, tics and any side effects of medication.
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AAP Practice Guideline
• Use and documentation of the AAP Practice Guideline meets requirement 3A of the Standards for the NCAA Patient Centered medical Home- “The practice Centered medical Home- “The practice adopts and implements evidence based guidelines…”
• Three conditions must be selected including one related to unhealthy behavior or a mental health or substance abuse condition.
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MTA Follow up Study
• MTA Study- Multimodal Treatment Study of Children with ADHD
• 4 distinct treatment groups
• 1. Medication management- stimulant • 1. Medication management- stimulant medication 3x daily 7 days per week with monthly visits
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MTA Follow up Study
• 2. Behavioral Management- 27 group sessions and 8 individual sessions along with an 8 week summer program and 12 weeks of classroom therapy with a half-time aide and 10 teacher consultation time aide and 10 teacher consultation sessions
• 3. Combination Management including both the medication program and the behavioral program
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MTA Follow up Study
• 4. Usual Community Care
• Initial study covered a 14month period
• All groups improved but Combination treatment and Medication Management treatment and Medication Management groups improved the most.
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MTA Follow up Study
• 10 months after study completed- Half of the initial advantage of the Combination and Medication Management groups was gone.gone.
• 3 years after study completed- Entire advantage of these groups was gone but some improvements over baseline continued for all 4 groups.
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MTA Follow up Study
• 6 and 8 years after study completed- No difference in outcomes based upon study group
• ADHD symptom trajectory in childhood • ADHD symptom trajectory in childhood strongly predicted outcome at 6 and 8 years
• The MTA children functioned less well than a non-ADHD classmate sample recruited at 24 months.
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MTA Follow up Study
• 6 and 8 years after study- Only 32.5% of the MTA children had taken medication for ADHD over half of the days in the past year.
• With the exception of math achievement, • With the exception of math achievement, medicated children were not faring better than non-medicated children
• Only 30% of the MTA children fulfilled DSM-IV criteria for ADHD at 8 year follow up
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MTA Follow up Study- What does this mean for us?
• Type and intensity of treatment MAY not be as important as initial symptom trajectory in predicting outcome
• Children with more severe initial • Children with more severe initial symptoms MAY benefit from more intense treatment and closer follow up but we simply don’t know this right now.
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Use of Standardized Rating Scales in the Diagnosis and Follow up of ADHD
• American Academy of Pediatrics Clinical Practice Guideline: Diagnosis and Evaluation of the Child with Attention-Deficit/Hyperactivity DisorderDeficit/Hyperactivity Disorder
• “The assessment of ADHD requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings…”
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Use of Standardized Rating Scales
• Use of specific rating scales for ADHD is a clinical option when evaluating children for ADHD.
• Use of broad band, global scales may not • Use of broad band, global scales may not be as accurate and is not recommended in the diagnosis of ADHD.
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Use of Standardized Rating Scales
• Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder.Deficit/Hyperactivity Disorder.
• American Academy of Child and Adolescent Psychiatry
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Use of Standardized Rating Scales
• Evaluation should include clinical interviews with parent and patient detailing school or day care function, medical, social and family history.social and family history.
• “The parent should complete one of the many standardized behavior rating scales that have well established normative values…”
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Relative Cost of Medications Used for ADHD
• Costs based on National Average Monthly Retail Prices May 2010
• Methylphenidate generic 40mg/day short acting tab-$40acting tab-$40
• Methylphenidate oral solution 40mg/day $530
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Relative Cost of Medications used to treat ADHD
• Methylphenidate long acting tablet
• Ritalin LA 40mg/day- $164
• Metadate CD 40mg/day- $240
• Concerta 54mg/day- 236• Concerta 54mg/day- 236
• Daytrana patch 20mg/day- $245
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Relative Cost of Medications used to treat ADHD
• Dexmethylphenidate
• Focalin 20mg/day generic $88
• Focalin XR 20mg/day $211
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Relative Cost of Medications used to Treat ADHD
• Mixed Amphetamine Salts
• Adderall 20mg/day generic $61
• Adderall XR 20mg/day generic $205
• Lisdexamfetamine
• Vyvanse 50mg/day $188
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PDSA Cycles to Consider dealing with ADHD treatment and follow up
• Compliance with the CHIPRA indicator for ADHD follow-up visits.
• Extract info to determine medication start dates and any previous ADHD treatment.dates and any previous ADHD treatment.
• Extract info to determine number of follow-up visits in the first month after initiation of treatment and in months 2 through 9.
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How do you extract data?
• Eventually we hope that we will be able to give you data extracted from your electronic health records, but we are not there yetthere yet
• 5 or 10 chart audits: Pull 5 to 10 charts per provider at a time to check for data. May not be statistically significant, but useful to ascertain trends for QI work
• Use billing codes (i.e. 96110 to indentify if a screen was used) or CPT codes
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PDSA Cycle Options
• Use of Standardized Rating Tools in the diagnosis and management of children with ADHD
• Extract data on children with diagnosis of • Extract data on children with diagnosis of ADHD
• Extract data on number of children with documented use of a standardized rating tool.
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PDSA Cycle Options- Standardized Rating Tool Use
• Educate Physicians about the use of Standardized Rating Tools
• Repeat Data Extraction over time and compare rates of rating tool usecompare rates of rating tool use
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PDSA Cycle Options- Cost control study of Stimulant Medications
• Obtain information on AWP of commonly used stimulant medications
• Extract data on use of various medications in children with diagnosis of ADHD.in children with diagnosis of ADHD.
• Educate Physicians on the comparative pricing of stimulant medications (realizing the impact that formularies have upon this issue)
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PDSA Cycle Options- Cost Control Study of ADHD Medications
• Continue to monitor use of various stimulant medications.
• It may be difficult to quantify outcome with this topic because patient needs are very this topic because patient needs are very variable and because insurance formulary coverage varies markedly.
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Resources for the Pediatrician Dealing with ADHD
• AAP ADHD Toolkit
• AAP Clinical Practice Guideline
• AACAP ADHD Practice Parameter
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Bibliography
• Molina, Brooke S.G., Stephen P. Hinshaw, James M. Swanson, et al. "The MTA at 8 Years." Journal of the American Academy of Child & Adolescent Psychiatry 48.5 of Child & Adolescent Psychiatry 48.5 (2009): 484-500. Print.
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Bibliography
• Contrast, By. "Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder --Subcommittee on Attention-Deficit/Hyperactivity Disorder and Committee on Quality Disorder and Committee on Quality Improvement 108 (4): 1033 -- AAP Policy." AAP Policy - Journal of the American Academy of
Pediatrics. Web. 11 Dec. 2010. <http://aappolicy.aappublications.org/cgi/content/full/pediatrics;108/4/1033>.
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Bibliography
• "AACAP Practice Parameters." National Resource Center on AD/HD: A Program of
CHADD. Web. 12 Dec. 2010. <http://www.help4adhd.org/treatment/guid<http://www.help4adhd.org/treatment/guides/aacap>.
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Bibliography
• "NCQA Public Policy CHIPRA Proposed Core Set." NCQA Home. Web. 16 Dec. 2010. <http://www.ncqa.org/tabid/1083/Default.a<http://www.ncqa.org/tabid/1083/Default.aspx>.
• (file is actually a PDF at this site)