Changes in Perceptions of Guideline-level Care for ADHD

in North CarolinaCharles Humble*, Marisa Domino†, Peter Jensen‡, Chris Kratochvilэ,

Alan Stiles† , Treiste Newton*, Lynn Wegner †‡, Steve Wegner*† ,

*AccessCare†UNC-CH Departments of Pediatrics and Health Policy & Management

‡Resource for Advancing Children’s Health (REACH) InstituteэUniversity of Nebraska Medical Center

APHA Annual Meeting, Mental Health Workforce 4135.0: October 30, 2012

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Presenter Disclosures

The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

Charles Humble, PhD

No relationships to disclose

Concerns with Current Pediatric Psychopharmacology

• Many children with behavioral health problems are never identified, diagnosed, or treated

• POOR Access to clinicians adequately trained in recognizing, diagnosing, and treating behavioral health problems is widespread nationally

• Growing evidence informs guidelines and practice parameters, BUT primary care clinicians are often unaware of these guidelines or unable to implement them in their practices

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• Attention Deficit/Hyperactivity Disorder (ADHD) is the most common behavioral health problem in children and adolescents

• Over last 7 years access to North Carolina’s public mental health programs has been challenged by re-design and funding cuts.

Background for North Carolina

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Program Goals• Give Primary Care Providers (PCP) and

Pediatric Residents the knowledge, skills, and tools needed to properly diagnose and manage ADHD and other common behavioral health conditions in the Medical Home

• Assess the possible added impact of training Case Managers (CM) with the knowledge, skills and tools needed to evaluate response to management plans and optimize adherence to management plans for care of children with ADHD 5

Provider Education Primary Care Providers (PCP)(Nov 2009)

3-day training in diagnosis of pediatric behavioral problems and primary pediatric psychopharmacology management (PPPM)- biweekly conference calls for 6 mo.

Care Managers (Nov 2009)1-day training in PPPM- biweekly conference calls for 6 mo.

Pediatric Residents (Aug & Sep 2010)1-day training in PPPM

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Training AgendaTraining Agenda

• Identify common ground and gaps between Primary Care & Child Psychiatry

• Discuss what is required to change how PCPs practice; reinforce thru role playing

• Review personal areas of need, set goals• Create Virtual Treatment Teams through bi-

weekly conference calls

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Final Samples

• ~ Half of sites randomized to Active Intervention & Standard Care Control Groups before training

• After deletion of 2 no-shows, 2 non-clinicians, 2 drop-outs, 1 hospitalist & non-AccessCare MD AND addition of 3 new CM :

17 Active practices: 15 CM/ 26 providers

14 Control practices: 11 CM/ 22 providers

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Post-Training Data CollectionUp to 44 of 48 PCPs responded surveys describing:

– Current Practice Characteristics– Norms of care in practices similar to their own– Knowledge of, comfort with, beliefs in, and

intention to implement and implementation of guideline-level care for ADHD

– Surveys administered immediately after training and again 6 & 12 months later

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Basic Demographics of PCPs

Provider Types Avg Sizes of Patient Panels

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Pediatrician FamPract NP PA0

5

10

15

20

25

30

35

40

N

Total Pediatric Peds with Behavior Dx0

10

20

30

40

50

60

70

80

90

100

Patients per week

PCP “Comfort” with Knowledge of Selected Behavioral Health Conditions

[Time of Training]

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ADHD Opp Defiant Disorder Conduct Disorder0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Excellent Good

PCP Attitudes re Clinical Practice Guidelines(CPG)

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Adjust Higher Dose when Sx Remain

Schedule Freq Visits F/U Tx Response*

Side Effect Scales P&T – Regular Visits

Sx Rating Scales – Regular Visits

Side Effect Scales – Weekly Titration

Sx Rating Scale Weekly – Initial Titration

Test Diff Doses Weekly – Initial Titration

Sx Rating Scale Teacher – Baseline

Sx Rating Scale Parent – Baseline

-5 -4 -3 -2 -1 0 1 2 3 4 5

Post-training 12 Months

Extremely Unfavorable Extremely Favorable* p < .05

Approval of CPG Usage by Colleagues

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Adjust Higher Dose when Sx Remain**

Schedule Freq Visits F/U Tx Response*

Side Effect Scales P&T – Regular Visits**

Sx Rating Scales – Regular Visits**

Side Effect Scales – Weekly Titration*

Sx Rating Scale Weekly – Initial Titration

Test Diff Doses Weekly – Initial Titration

Sx Rating Scale Teacher – Baseline*

Sx Rating Scale Parent – Baseline

-5 -4 -3 -2 -1 0 1 2 3 4 5

Post-training 12 Months

Strongly Disapprove Strongly Approve* p < .05** p < .01

Perceived Ability to Use CPGs for ADHD

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Adjust Higher Dose when Sx Remain*

Schedule Freq Visits F/U Tx Response**

Side Effect Scales P&T – Regular Visits

Sx Rating Scales – Regular Visits

Side Effect Scales – Weekly Titration

Sx Rating Scale Weekly – Initial Titration**

Test Diff Doses Weekly – Initial Titration*

Sx Rating Scale Teacher – Baseline

Sx Rating Scale Parent – Baseline

0 1 2 3 4 5 6 7 8 9 10

Post Training 12 Months

Very Hard Extremely Easy* p < .05** p < .01

PCP-perceived Obstacles to Optimal Care

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Lack Training Use Side Effect Scales***

Lack Standard Side Effect Scales***

Lack Time Frequent F/U Visits**

Lack Time Titrate to Optimal Dose

Standard Scales take Too Much Time***

Standard Sx Scales Not Available***

Standard Sx Scales Inconvenient

Formulary restrictions or Costs Optimal Rx

0 1 2 3 4 5 6 7 8 9 10

Post-training 12 Months

* p < .05 ** p < .01*** p < .001 Never an Obstacle Always an Obstacle

Chart Review Data re:PCP Use of 1+ Parent VD Rating Scales

Pre- vs. Post-Training (n=188)

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Time Post ADHD Diagnosis

* p<.05 ** p<.01*** p<.00001

***

*

**

Chart Review Data re:PCP Use of 1+ Teacher VD Rating Scales

Pre- vs. Post-Training (n=188)

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Time Post ADHD Diagnosis

* p<.01 ** p<.001

**

* *

Chart Review Data re:PCP Use of 1+ Parent SE Rating Scales

Pre- vs. Post-Training (n=188)

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Time Post ADHD Diagnosis

--No significant differences --

Conclusions• PCPs retained their positive attitudes toward guideline-level

ADHD treatments for pediatric patients 12 months after an intense 3-day training

• Perceived attitudes of colleagues toward use of most CPGs for ADHD care remained high or increased

• Perceived ability to use most CPGs for ADHD care remained high or increased

• Most perceived Obstacles to guideline-use diminished over the 12 months of follow-up

• Chart reviews show increased use of ADHD symptom screeners and greater frequency of F/U visits

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Limitations• Baseline data were collected after the initial training

– Can infer a training effect from initial high rankings– Analyses test changes relative to these high levels & most

directly test effects of biweekly conference calls (6 mo.)– Sample sizes of 38 to 44 /survey limit analytic power

• Fixed Effect models found stable or modest levels of improvement for most outcome measures.

• Supplemental analyses using Change Models will attempt to identify individual participants with greatest likelihood for improved outcomes.

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Study Significance• Findings support the value of extended PCP training in

guideline-level care for ADHD

• Findings are informing rollout of other Behavioral Health programs in NC’s Medicaid program

• May also influence use of REACH model in other states now adopting the Medical Home model for their Medicaid clients

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Major support for this project comes from ARRA Grant # 1RC1MH088922-01.

The authors thank Dr. Lisa Hunter, Melanie Louis and Courtney Sanderson for their many

contributions to this program. Timothy O’Brien & Matt Caldwell helped with the analyses.

For more information contact

Charles Humble, PhDchumble@ncaccesscare.org

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