Follow-Up Care for Children Prescribed ADHD Medication (ADD)

Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported.  
a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.
b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.

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Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood and can profoundly affect the academic achievement, well-being, and social interactions of children (American Academy of Pediatrics, 2011). The American Psychiatric Association states in the Diagnostic and Statistical Manual of Mental Disorders that five percent of children have ADHD (American Psychiatric Association, 2013). However, other studies in the US have estimated higher rates in community samples. For example, a study examining data from the National Survey of Children's Health estimated that approximately 9.4% of children 2-17 years of age (6.1 million) had ever been diagnosed with ADHD, according to parent report in 2016 (Danielson et al., 2016). Among those children, 6 out of 10 (62%) were taking medication for their ADHD and represent 1 out of 20 of all U.S. children. Just under half (47%) received any behavioral treatment for their ADHD in the past year (Danielson et al., 2016). 

There are many symptoms associated with ADHD. Children with ADHD may experience significant functional problems, such as school difficulties, academic underachievement, troublesome relationships with family members and peers and behavioral problems (American Academy of Pediatrics, 2000). For instance, recent studies have found that parents whose children have a history of ADHD report significantly more peer problems and a higher rate of non-fatal injuries compared to parents whose children do not have a history of ADHD (Strine et al., 2006; Xiang et al., 2005). Additional studies suggest that there is an increased risk for drug use disorders in adolescents with untreated ADHD (National Institute on Drug Abuse, 2010). One of the national objectives of the Department of Health and Human Services Healthy People 2020 initiative is to increase the proportion of children with mental health problems who receive treatment.

Medication treatment has been found to be effective for managing ADHD, but requires careful monitoring by physicians. Studies have shown that psychostimulants are highly effective for 75-90% of children with ADHD by reducing symptoms of hyperactivity, impulsivity and inattention; improving classroom performance and behavior; and promoting increased interaction with teachers, parents and peers (U.S. Department of Health and Human Services, 1999). Some reported adverse effects of stimulant ADHD medications include appetite loss, abdominal pain, headaches, sleep disturbance, decreasing growth velocity, and less commonly, hallucinations and other psychotic symptoms. Additionally, treatments for children with ADHD are frequently not sustained despite the fact that they are at greater risk of significant problems if they discontinue treatment (Wolraich et al., 2011). Effective management mitigates the risk of discontinuing treatment.

The intent of this measure is to ensure timely and continuous follow-up visits for children who are newly prescribed ADHD medication. The goal is to encourage monitoring of children for medication effectiveness, occurrence of side effects and adherence.

American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter for the Assessment and Treatment of Children and Adolescents with ADHD

- Overall Guideline
The key to effective long-term management of the patient with ADHD is continuity of care with a clinician experienced in the treatment of ADHD. The frequency and duration of follow-up sessions should be individualized for each family and patient, depending on the severity of ADHD symptoms; the degree of comorbidity of other psychiatric illness; the response to treatment; and the degree of impairment in home, school, work, or peer-related activities. The clinician should establish an effective mechanism for receiving feedback from the family and other important informants in the patient's environment to be sure symptoms are well controlled and side effects are minimal. Although this parameter does not seek to set a formula for the method of follow-up, significant contact with the clinician should typically occur two to four times per year in cases of uncomplicated ADHD and up to weekly sessions at times of severe dysfunction or complications of treatment.

- Recommendation 6: A Well-Thought-Out and Comprehensive Treatment Plan Should Be Developed for the Patient With ADHD. The treatment plan should be reviewed regularly and modified if the patient's symptoms do not respond. Minimal Standard [MS]

- Recommendation 9. During a Psychopharmacological Intervention for ADHD, the Patient Should Be Monitored for Treatment-Emergent Side Effects. Minimal Standard [MS]

- Recommendation 12. Patients Should Be Assessed Periodically to Determine Whether There Is Continued Need for Treatment or If Symptoms Have Remitted. Treatment of ADHD Should Continue as Long as Symptoms Remain Present and Cause Impairment. Minimal Standard [MS]

American Academy of Pediatrics Clinical Practice Guideline for the Diagnosis, Evaluation and Treatment of ADHD in Children and Adolescents

Key Action Statement (KAS) 1: The pediatrician or other primary care clinicians (PCC) should initiate an evaluation for ADHD for any child or adolescent age 4 years to the 18th birthday who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity. Grade B: Strong Recommendation

KAS 4: ADHD is a chronic condition; therefore, the PCC should manage children and adolescents with ADHD in the same manner that they would children and youth with special health care needs, following the principles of the chronic care model and the medical home. Grade B: Strong Recommendation

KAS 5b: For elementary and middle school-aged children (age 6 years to the 12th birthday) with ADHD, the PCC should prescribe FDA-approved medications for ADHD, along with parent training in behavior management (PTBM) and/or behavioral classroom intervention (preferably both PTBM and behavioral classroom interventions). Educational interventions and individualized instructional supports, including school environment, class placement, instructional placement, and behavioral supports, are a necessary part of any treatment plan and often include an IEP or a rehabilitation plan (504 plan). Grade A: Strong Recommendation

Higher score indicates better quality

Reference Type: CITATION

Reference Text: 'American Academy of Pediatrics. (2019, September). ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics, 144(4), 1-25.'

Reference Type: CITATION

Reference Text: 'American Academy of Pediatrics. (2000). Clinical practice guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics, 105(5), 1158-1170.'

Reference Type: CITATION

Reference Text: 'American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, 5th edition (DSM-5). Washington, DC: Author.'

Reference Type: CITATION

Reference Text: 'Danielson, M. L., Bitsko, R. H., Ghandour, R. M., et al. (2016). Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents. Journal of Clinical Child & Adolescent Psychology, 47(2), 199-212.'

Reference Type: CITATION

Reference Text: 'Jensen, P., Hinshaw, S. P., Swanson, J. M., et al. (2001). Findings from the NIMH multimodal treatment study of ADHD (MTA): Implications and applications for primary care providers. Journal of Developmental and Behavioral Pediatrics, 22(1), 60-73.'

Reference Type: CITATION

Reference Text: 'National Institute on Drug Abuse. (2010, September). Comorbidity: Addiction and Other Mental Illnesses. Retrieved from https://www.drugabuse.gov/sites/default/files/rrcomorbidity.pdf'

Reference Type: CITATION

Reference Text: 'Pliszka, S., & AACAP Work Group on Quality Issues. (2007). Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 46(7), 894-921.'

Reference Type: CITATION

Reference Text: 'Robb, J. A., Sibley, M. H., Pelham, W. E., Jr., et al. (2011, September). The estimated annual cost of ADHD to the U.S. education system. School Mental Health, 3(3), 169-177. Retrieved from http://link.springer.com/article/10.1007/s12310-011-9057-6#'

Reference Type: CITATION

Reference Text: 'Strine, T. W., Lesesne, C. A., Okoro, C. A., et al. (2006). Emotional and behavioral difficulties and impairments in everyday functioning among children with a history of attention-deficit/hyperactivity disorder. Preventing Chronic Disease, 3(2), A52.'

Reference Type: CITATION

Reference Text: 'Swensen, A. R., Birnbaum, H. G., Secnik, K., et al. (2003). Attention-deficit/hyperactivity disorder: Increased costs for patients and their families. Journal of the American Academy of Child Adolescent Psychiatry, 42(12), 1415-1423.'

Reference Type: CITATION

Reference Text: 'U.S. Department of Health and Human Services. (1999). Mental health: A report of the surgeon general. Retrieved from http://profiles.nlm.nih.gov/ps/retrieve/ResourceMetadata/NNBBHS'

Reference Type: CITATION

Reference Text: 'Wolraich, M., Brown, L., Brown, R. T., et al. (2011). ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 128(5), 1007-1022.'

Reference Type: CITATION

Reference Text: 'Xiang, H., Stallones, L., Chen, G., et al. (2005). Nonfatal injuries among U.S. children with disabling conditions: Opportunity for improvement. American Journal of Public Health, 95(11), 1970-1975.'

Intake Period: The five-month period starting 90 days prior to the start of the measurement period and ending 60 days after the start of the measurement period. 

Index Prescription Start Date (IPSD): The earliest prescription dispensing date for an ADHD medication where the date is in the Intake Period and an ADHD medication was not dispensed during the 120 days prior. 

Initiation Phase: The 30 days following the IPSD. 

Continuation and Maintenance Phase: The 31-300 days following the IPSD.

This eCQM is a patient-based measure.
 
This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

Initial Population 1: Children 6-12 years of age who were dispensed an ADHD medication during the Intake Period and who had a visit during the measurement period.

Initial Population 2: Children 6-12 years of age who were dispensed an ADHD medication during the Intake Period and who remained on the medication for at least 210 days out of the 300 days following the IPSD, and who had a visit during the measurement period.

Equals Initial Population

Denominator Exclusion 1: Exclude patients diagnosed with narcolepsy at any point in their history or during the measurement period.

Exclude patients who had an acute inpatient stay with a principal diagnosis of mental health or substance abuse during the 30 days after the IPSD. 

Exclude patients who were actively on an ADHD medication in the 120 days prior to the Index Prescription Start Date. 

Exclude patients who are in hospice care for any part of the measurement period.

Denominator Exclusion 2: Exclude patients diagnosed with narcolepsy at any point in their history or during the measurement period.

Exclude patients who had an acute inpatient stay with a principal diagnosis of mental health or substance abuse during the 300 days after the IPSD.

Exclude patients who were actively on an ADHD medication in the 120 days prior to the Index Prescription Start Date.

Exclude patients who are in hospice care for any part of the measurement period.

Numerator 1: Patients who had at least one visit with a practitioner with prescribing authority within 30 days after the IPSD.
 
Numerator 2: Patients who had at least one visit with a practitioner with prescribing authority during the Initiation Phase, and at least two follow-up visits during the Continuation and Maintenance Phase.

Not Applicable

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For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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