Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA.
Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA.
J Child Adolesc Psychopharmacol. 2020 Jun;30(5):285-292. doi: 10.1089/cap.2020.0013. Epub 2020 Mar 11.
We examined primary care providers' (PCPs') management of attention-deficit/hyperactivity disorder (ADHD) during and following families' participation in two arms of the Children's ADHD Telemental Health Treatment Study. We hypothesized that more intensive treatment during the trial would show an "after-effect" with more assertive PCPs' management during short term follow-up. We conducted a pragmatic follow-up of PCPs' management of children with ADHD who had been randomized to two service delivery models. In the Direct Service Model, psychiatrists provided six sessions over 22 weeks of pharmacotherapy followed by behavior training. In the Consultation Model, psychiatrists provided a single-session consultation and made treatment recommendations to PCPs who implemented these recommendations at their discretion for 22 weeks. At the end of the trial, referring PCPs for both service delivery models resumed ADHD treatment for 10 weeks. We performed intent-to-treat analysis using all 223 original participants. We applied linear regression models on continuous outcomes, Poisson regression models on count outcomes, and logistic regression models to binary outcomes. Missing data were addressed through imputations. Participants in the Direct Service Model had more ADHD visits than those in the Consultation Model across the full 32 weeks (mean = 7.05 visits vs. 3.36 visits; adjusted rate ratio = 2.1 [1.85-2.38]; < 0.0001). During follow-up, participants in the DSM were more likely to be taking ADHD-related medications (82% vs. 61%; adjusted odds ratio = 2.44 [1.24-4.81], = 0.01). At 32 weeks, participants in the Direct Service Model had higher stimulant dosages (adjusted difference = 5.64 [0.12-11.15] mg; = 0.046). These results from a pragmatic follow-up of a randomized trial suggest an "after-effect" for brief intensive treatment in the Direct Service Model on the short term follow-up management of ADHD in primary care.
我们考察了初级保健提供者（PCP）在参与儿童注意缺陷多动障碍（ADHD）的两种治疗模式期间和之后对 ADHD 的管理。我们假设，在试验期间进行更密集的治疗，会在短期随访期间显示出 PCP 更积极的管理效果。我们对参加儿童 ADHD 远程心理健康治疗研究的儿童进行了一项实用的后续研究，这些儿童被随机分配到两种服务提供模式。在直接服务模式中，精神科医生在 22 周内提供六次药物治疗，随后进行行为训练。在咨询模式中，精神科医生提供单次咨询，并向 PCP 提出治疗建议，由 PCP 根据自己的判断在 22 周内实施这些建议。试验结束时，两种服务提供模式的转诊 PCP 都恢复 ADHD 治疗 10 周。我们对所有 223 名原始参与者进行意向治疗分析。我们对连续结果应用线性回归模型，对计数结果应用泊松回归模型，对二项结果应用逻辑回归模型。通过插补处理缺失数据。在整个 32 周内，直接服务模式组的 ADHD 就诊次数多于咨询模式组（平均就诊次数 7.05 次 vs. 3.36 次；调整后的就诊率比为 2.1[1.85-2.38]；<0.0001）。在随访期间，直接服务模式组服用 ADHD 相关药物的可能性更高（82% vs. 61%；调整后的优势比为 2.44[1.24-4.81]，=0.01）。在 32 周时，直接服务模式组的兴奋剂剂量更高（调整后的差异为 5.64[0.12-11.15]mg；=0.046）。这项来自随机试验实用后续研究的结果表明，直接服务模式中的简短强化治疗在短期随访中对 ADHD 的初级保健管理具有“后效”。
