Distance-Learning, ADHD Quality Improvement in Primary Care: A Cluster-Randomized Trial

Abstract

Objective: To evaluate a distance-learning, quality improvement intervention to improve pediatric primary care provider use of attention-deficit/hyperactivity disorder (ADHD) rating scales.

Methods: Primary care practices were cluster randomized to a 3-part distance-learning, quality improvement intervention (web-based education, collaborative consultation with ADHD experts, and performance feedback reports/calls), qualifying for Maintenance of Certification (MOC) Part IV credit, or wait-list control. We compared changes relative to a baseline period in rating scale use by study arm using logistic regression clustered by practice (primary analysis) and examined effect modification by level of clinician participation. An electronic health record-linked system for gathering ADHD rating scales from parents and teachers was implemented before the intervention period at all sites. Rating scale use was ascertained by manual chart review.

Results: One hundred five clinicians at 19 sites participated. Differences between arms were not significant. From the baseline to intervention period and after implementation of the electronic system, clinicians in both study arms were significantly more likely to administer and receive parent and teacher rating scales. Among intervention clinicians, those who participated in at least 1 feedback call or qualified for MOC credit were more likely to give parents rating scales with differences of 14.2 (95% confidence interval [CI], 0.6-27.7) and 18.8 (95% CI, 1.9-35.7) percentage points, respectively.

Conclusion: A 3-part clinician-focused distance-learning, quality improvement intervention did not improve rating scale use. Complementary strategies that support workflows and more fully engage clinicians may be needed to bolster care. Electronic systems that gather rating scales may help achieve this goal. Index terms: ADHD, primary care, quality improvement, clinical decision support.

Figure 1

Consort Diagram for SHARE Cluster Randomized Controlled Trial. The percentage of clinicians participating across the 19 practices varied. Clinician participation rate within intervention practices: mean 71%, interquartile range 39%–74%, range 29%–100%. Clinician participation rate within control practices: mean 60%, interquartile range 57%–80%, range 14–100%. Participation rates did not differ significantly between study arms.

Figure 2

Change in the Percent of Eligible Patients for whom Clinicians Sent Out Parent ADHD Rating Scales at Each Practice (from Baseline to Intervention Period, calculated as the total number of surveys sent out by providers in the practice divided by the total number of charts reviewed for that practice per study period), N=19 Primary Care Practices. + refers to the number of participating clinicians divided by the total number of clinicians in the practice. * indicates urban teaching practices with embedded mental health providers. Participation rates did not differ significantly between study arms.