Bussing Regina, Narwaney Komal J, Winterstein Almut G, Newton Douglas A, DeBar Lynn, Boscarino Joseph A, Toh Sengwee, Pawloski Pamala, Nordin James D, Herrinton Lisa J, Mason Dana, Daley Matthew F
University of Florida, College of Medicine , Gainesville, FL , USA.
Curr Med Res Opin. 2014 Aug;30(8):1687-99. doi: 10.1185/03007995.2014.905461. Epub 2014 Apr 7.
This study examines incident treatment patterns for attention-deficit/hyperactivity disorder (ADHD) in children seen in eight integrated healthcare delivery systems and identifies factors associated with adherence to Healthcare Effectiveness Data and Information Set (HEDIS) quality measures developed by the National Committee for Quality Assurance (NCQA).
A retrospective cohort analysis using electronic healthcare data from children aged 3 through 17 years with newly diagnosed ADHD between January 1, 2009 and December 31, 2010 was conducted. NCQA quality definitions for initiation and for continuation and maintenance (C&M) of ADHD medications were expanded to include preschoolers and adolescents. Poisson regression models with robust error variance were used to evaluate the association between NCQA HEDIS adherence measures, provider type, patient characteristics and care process measures.
Of 6864 children aged 3-17 years old qualifying for incident treatment analyses, 5538 (80.7%) were started on ADHD medication within a year of diagnosis. Adherence to NCQA HEDIS measures was 49.8% for initiation and 45.8% for C&M, with adherence rates higher for mental health than non-mental health providers, school-aged children than adolescents, and for patients concurrently on other psychotropic medications than those who were not. Of those started on ADHD medication, 62.3% were not eligible for C&M analyses according to HEDIS guidelines, because they did not receive continuous (210 of 300 days) ADHD medication treatment, with adolescents less likely than school-aged children to persist with medications.
Study limitations must be considered, including reliance on electronic medical record data, absence of patient race and sociodemographic data, and limited generalizability to other care contexts. Nevertheless, findings suggest novel strategies are needed to improve the quality of ADHD care processes for children of all ages, because even within integrated delivery systems less than half of children with ADHD received care consistent with NCQA HEDIS standards for initiation and C&M care. RESULTS suggest the need to refine quality measures by including follow-up care in those children not receiving or discontinuing medication treatment, a considerable quality concern not currently captured in NCQA HEDIS standards.
本研究调查了在八个综合医疗保健服务系统中接受治疗的儿童注意力缺陷多动障碍（ADHD）的发病治疗模式，并确定了与遵守国家质量保证委员会（NCQA）制定的医疗保健有效性数据和信息集（HEDIS）质量指标相关的因素。
进行了一项回顾性队列分析，使用了2009年1月1日至2010年12月31日期间3至17岁新诊断为ADHD的儿童的电子医疗数据。NCQA对ADHD药物起始治疗以及持续和维持治疗（C&M）的质量定义进行了扩展，将学龄前儿童和青少年纳入其中。使用具有稳健误差方差的泊松回归模型来评估NCQA HEDIS依从性指标、提供者类型、患者特征和护理过程指标之间的关联。
在6864名符合发病治疗分析条件的3至17岁儿童中，5538名（80.7%）在诊断后一年内开始使用ADHD药物治疗。NCQA HEDIS指标的起始治疗依从率为49.8%，C&M治疗依从率为45.8%，心理健康提供者的依从率高于非心理健康提供者，学龄儿童高于青少年，同时使用其他精神药物的患者高于未使用的患者。在开始使用ADHD药物治疗的患者中，根据HEDIS指南，62.3%的患者不符合C&M分析条件，因为他们没有接受持续（300天中的210天）ADHD药物治疗，青少年坚持用药的可能性低于学龄儿童。
必须考虑研究的局限性，包括对电子病历数据的依赖、缺乏患者种族和社会人口统计学数据以及对其他护理环境的普遍适用性有限。然而，研究结果表明，需要采取新的策略来提高各年龄段儿童ADHD护理过程的质量，因为即使在综合医疗服务系统中，不到一半的ADHD儿童接受的护理符合NCQA HEDIS起始治疗和C&M护理标准。结果表明，需要通过将后续护理纳入未接受或停止药物治疗的儿童中来完善质量指标，这是NCQA HEDIS标准目前未涵盖的一个相当大的质量问题。
