Use of practice guidelines in the primary care of children with attention-deficit/hyperactivity disorder.

Objectives. Several guidelines have been published for the care of children with attention- deficit/hyperactivity disorder (ADHD); however, few data describe adoption of practice guidelines. Our study sought 1) to describe primary care diagnosis and man- agement of ADHD, 2) to determine whether the care is in accordance with American Academy of Pediatrics (AAP) practice guidelines, and 3) to describe factors associated with guideline adherence. Methods. We conducted a mail survey of 1374 pri- mary care physicians in Michigan. Main outcome mea- sures were reported adherence to practices specified in the AAP guidelines; ADHD practice patterns; and other measures, including attitudes about parent, teacher, and community influences on ADHD diagnosis and treat- ment. Bivariate and multivariate analyses were per- formed to assess patient and physician factors associated with adherence to guideline components. Results. The overall response rate was 60%. The ma- jority (77.4%) of primary care physicians were familiar with AAP guidelines on ADHD, and many (61.1%) re- ported incorporating the guidelines into their practice. Differences were apparent by specialty: 91.5% of pedia- tricians were familiar with the guidelines in contrast to 59.8% of family physicians. The majority of clinicians reported practices consistent with individual compo- nents of the diagnostic and treatment guidelines. How- ever, when adherence to multiple components was ana- lyzed together, only 25.8% of clinicians reported routine use of all 4 diagnostic components in the survey. In addition, some physicians continue to use diagnostic mo- dalities that are currently not recommended for routine evaluation of school-aged children with ADHD— contin- uous performance testing, neuroimaging, and laboratory tests (eg, thyroid, lead, or iron testing). With regard to ADHD treatment, the majority (66.6%) of respondents reported routine recommendation of pharmacotherapy and titration of medications in the first month when prescribed (81.3%). However, just over half (53.1%) re- ported routine follow-up visits (3- 4 times per year) for children who have ADHD and are taking medications. Most (53.4%) clinicians also recommended behavioral therapy for children who had a diagnosis of ADHD. Patterns of specialty differences were less consistent for treatment components: pediatricians were more likely to recommend medications, but family physicians reported more frequent follow-up evaluations for children who receive medications. There were no specialty differences in recommendations for behavioral therapy. In addition to physician specialty variations, differences in manage- ment were apparent by practice type and other demo- graphic characteristics. There were few significant asso- ciations between adherence to guideline components and physician attitudes about parent, teacher, or community influences. However, these factors were noted by many respondents. Only 32.5% agreed that their community had adequate, accessible mental health resources. Half (50.1%) of the physicians reported that insurers limit coverage for assessment and treatment of ADHD. Conclusions. Primary care physicians generally re- port awareness of pediatric ADHD guidelines and follow these clinical practice recommendations. However, some physician variations are apparent, and areas for improve- ment are noted. Many primary care physicians report poor access to mental health services, limited insurance coverage, and other potential system barriers to the de- livery of ADHD care. Additional study is needed to confirm provider-reported data; to determine what con- stitutes high-quality, long-term management of this chronic condition; and to confirm how reported practices associate with long-term outcomes for children with ADHD. Pediatrics 2004;114:e23-e28. URL: http://www. pediatrics.org/cgi/content/full/114/1/e23; attention- deficit/hyperactivity disorder, pediatrics, family physi- cians, practice guidelines, CNS stimulants, mental health services.