A Planned Care Approach and Patient Registry to Improve Adherence to Clinical Guidelines for the Diagnosis and Management of Attention-Deficit/Hyperactivity Disorder



      Attention-deficit/hyperactivity disorder (ADHD) affects almost 2.4 million US children. Because American Academy of Pediatrics guidelines for ADHD recommend use of standardized diagnostic instruments, regular follow-up and the chronic care model, this pilot project sought to implement and assess an electronic registry of patients with ADHD combined with care coordination by a planned care team.


      This quality improvement project was structured with 2 intervention and 2 control clinics to facilitate evaluation of the use of a planned care system for management of ADHD. Care teams included a pediatrician, nurse, medical assistant, and care coordinator and tracked patients using an electronic registry with data drawn from the EMR. Clinical work flows were pilot tested to facilitate use of the Vanderbilt scales and their incorporation into the EMR at intervention sites. Outcome measures included 2 recommended clinical follow-ups based on HEDIS measures as well as use of the Vanderbilt rating scales. Initiation phase measure was for follow-up after initiating medication, while the continuation phase measure was for subsequent follow-up during the first year of treatment. Measures were monitored during the project year and then also in the ensuing period of spread of the intervention to other sites.


      Although the modified HEDIS initiation phase measure for patients newly on medication remained static at approximately 50% throughout the project period, the continuation phase measure showed improvement from 35% at baseline to 45% at the end of the project assessment year, a 29% increase. Follow-up for patients stable on medications also remained unchanged during the project period, but during subsequent spreading of the intervention to nonproject sites, follow-up of these patients improved to over 90%. In adjusted analyses, patients with ADHD at intervention sites were over 2 times more likely than patients at control sites to have had a Vanderbilt score documented in their records.


      The project achieved modest improvements in the diagnostic and treatment process for patients with ADHD. The use of a planned care system and electronic patient registry shows promise for improving the diagnosis and treatment process for patients with ADHD.


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        • Centers for Disease Control and Prevention
        Mental health in the United States: prevalence of diagnosis and medication treatment for attention-deficit/hyperactivity disorder: United States, 2003.
        MMWR Morb Mortal Wkly Rep. 2005; 54: 842-847
        • Froehlich T.E.
        • Lanphear B.P.
        • Epstein J.N.
        • et al.
        Prevalence, recognition, and treatment of attention-deficit/hyperactivity disorder in a national sample of US children.
        Arch Pediatr Adolesc Med. 2007; 161: 857-864
        • MTA Cooperative Group
        A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder.
        Arch Gen Psychiatry. 1999; 56: 1073-1086
        • MTA Cooperative Group
        Moderators and mediators of treatment response for children with attention-deficit/hyperactivity disorder.
        Arch Gen Psychiatry. 1999; 56: 1088-1096
        • Biederman J.
        • Monuteaux M.C.
        • Spencer T.
        • et al.
        Do stimulants protect against psychiatric disorders in youth with ADHD? A 10-year follow-up study.
        Pediatrics. 2009; 124: 71-78
        • Epstein J.N.
        • Langberg J.M.
        • Lichtenstein P.K.
        • et al.
        Attention-deficit/hyperactivity disorder outcomes for children treated in community-based pediatric settings.
        Arch Pediatr Adolesc Med. 2010; 164: 160-165
        • Sayal K.
        • Owen V.
        • White K.
        • et al.
        Impact of early school-based screening and intervention programs for ADHD on children’s outcomes and access to services: follow-up of a school-based trial at age 10 years.
        Arch Pediatr Adolesc Med. 2010; 164: 462-469
        • American Academy of Pediatrics
        • Committee on Quality Improvement
        • Subcommittee on Attention-Deficit/Hyperactivity Disorder
        Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder.
        Pediatrics. 2000; 105: 1158-1170
        • American Academy of Pediatrics
        • Committee on Quality Improvement
        • Subcommittee on Attention-Deficit/Hyperactivity Disorder
        Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder.
        Pediatrics. 2000; 108: 1033-1044
        • American Academy of Pediatrics
        • Subcommittee on Attention-Deficit/Hyperactivity Disorder
        • Steering Committee on Quality Improvement and Management
        ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents.
        Pediatrics. 2011; 128: 1007-1022
        • Wolraich M.L.
        • Lambert E.W.
        • Worley K.A.
        • et al.
        Psychometric properties of the Vanderbilt ADHD diagnostic parent rating scale in a referred population.
        J Pediatr Psychol. 2003; 28: 559-568
      1. National Institute for Children's Health Quality. Child health topics: ADHD. Available at: Accessed June 24, 2011.

        • Rushton J.L.
        • Fant K.E.
        • Clark S.J.
        Use of practice guidelines in the primary care of children with attention-deficit/hyperactivity disorder.
        Pediatrics. 2004; 114: e23-e28
        • Ray G.T.
        • Levine P.
        • Croen L.A.
        • et al.
        Attention-deficit/hyperactivity disorder in children: excess costs before and after initial diagnosis and treatment cost differences by ethnicity.
        Arch Pediatr Adolesc Med. 2006; 160: 1063-1069
        • Larson K.
        • Russ S.A.
        • Kahn R.S.
        • et al.
        Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007.
        Pediatrics. 2011; 127: 462-470
        • Leslie L.K.
        • Weckerly J.
        • Plammons D.
        • et al.
        Implementing the American Academy of Pediatrics attention-deficit/hyperactivity disorder diagnostic guidelines in primary care settings.
        Pediatrics. 2004; 114: 129-140
        • Wagner E.H.
        Chronic disease management: what will it take to improve care for chronic illness?.
        Eff Clin Pract. 1998; 1: 2-4
        • Lavigne J.V.
        • Dulcan M.K.
        • Lebailly S.A.
        • et al.
        Computer-assisted management of attention-deficit/hyperactivity disorder.
        Pediatrics. 2011; 128: e1-e8
        • Co J.P.T.
        • Johnson S.A.
        • Poon E.G.
        • et al.
        Electronic health record decision support and quality of care for children with ADHD.
        Pediatrics. 2010; 126: 239-246
      2. National Committee for Quality Assurance. Follow-up care for children prescribed ADHD medication. Available at: Accessed July 5, 2011.

        • Hacker K.A.
        • Penfold R.
        • Arsenault L.
        • et al.
        Screening for behavioral health issues in children enrolled in Massachusetts Medicaid.
        Pediatrics. 2014; 133: 46-54
        • Boaden R.J.
        • Harvey G.
        • Moxham C.
        • et al.
        Quality Improvement: Theory and Practice in Healthcare.
        NHS Institute for Innovation and Improvement, Coventry, UK2008
        • Lavigne J.V.
        • Dulcan M.K.
        • LeBailly S.A.
        • et al.
        Computer-assisted management of attention-deficit/hyperactivity disorder.
        Pediatrics. 2011; 128: e46-e53
        • Carroll A.E.
        • Bauer N.S.
        • Dugan T.M.
        • et al.
        Use of a computerized decision aid for ADHD diagnosis: a randomized controlled trial.
        Pediatrics. 2013; 132: e623-e629
        • Brinkman W.B.
        • Hartl Majcher J.
        • Pling L.M.
        • et al.
        Shared decision-making to improve attention-deficit hyperactivity disorder.
        Patient Educ Couns. 2013; 93: 95-101
        • Olfson M.
        • Garmeroff M.J.
        • Marcus S.C.
        • Jensen P.S.
        National trends in the treatment of attention deficit hyperactivity disorder.
        Am J Psychiatry. 2003; 160: 1071-1077
        • Stevens J.
        • Harman J.S.
        • Kelleher K.J.
        Race/ethnicity and insurance status as factors associated with ADHD treatment patterns.
        J Child Adolesc Psychopharmacol. 2005; 15: 88-96
        • Rowland A.S.
        • Umback D.M.
        • Sallone L.
        • et al.
        Prevalence of medication treatment for attention deficit-hyperactivity disorder among elementary school children in Johnston County, North Carolina.
        Am J Public Health. 2002; 92: 231-234
        • Hoagwood K.
        • Jensen P.S.
        • Feil M.
        • et al.
        Medication management of stimulants in pediatric practice settings: a national perspective.
        J Dev Behav Pediatr. 2000; 21: 322-331
        • Fiks A.G.
        • Localio A.R.
        • Alessandrini E.A.
        • et al.
        Shared decision-making in pediatrics: a national perspective.
        Pediatrics. 2010; 126: 306-314
        • Fiks A.G.
        • Hughes C.C.
        • Gafen A.
        • et al.
        Contrasting parents’ and pediatricians’ perspectives on shared decision-making in ADHD.
        Pediatrics. 2011; 127: e188-e196