Use of practice guidelines in the primary care of children with attention-deficit/hyperactivity disorder
Use of practice guidelines in the primary care of children with attention-deficit/hyperactivity disorder
复制标题
DOI：
10.1542/peds.114.1.e23
复制
发表时间：
2004-07-01
期刊：
影响因子：
8
通讯作者：
Clark, SJ
中科院分区：
文献类型：
--
作者：
Rushton, JL;Fant, KE;Clark, SJ
目标。关于注意缺陷/多动障碍(ADHD)儿童的护理，已经公布了几个指南；然而，很少有数据描述实践指南的采用情况。我们的研究试图1)描述ADHD的初级保健诊断和处理，2)确定护理是否符合美国儿科学会(AAP)的实践指南，以及3)描述与指南遵守相关的因素。我们对密歇根州的1374名初级保健医生进行了邮寄调查。主要结果指标是报告遵守AAP指南中规定的做法；ADHD实践模式；以及其他措施，包括对父母、教师和社区对ADHD诊断和治疗的影响的态度。采用双变量和多变量分析来评估与遵守指南成分相关的患者和医生因素。总有效率为60%。大多数(77.4%)的初级保健医生熟悉AAP关于ADHD的指南，许多(61.1%)的医生报告将这些指南纳入他们的实践。不同的专业有明显的差异：91.5%的儿科医生熟悉指南，而家庭医生的这一比例为59.8%。大多数临床医生报告的做法与诊断和治疗指南的个别组成部分一致。然而，当同时分析对多种成分的依从性时，只有25.8%的临床医生报告在调查中常规使用所有4种诊断成分。此外，一些医生继续使用目前不推荐用于对患有ADHD的学龄儿童进行常规评估的诊断方法-连续表现测试、神经成像和实验室测试(如甲状腺、铅或铁测试)。关于ADHD的治疗，大多数(66.6%)的受访者在处方的第一个月报告了常规的药物治疗和药物滴定(81.3%)。然而，略多于一半(53.1%)的儿童报告了对患有ADHD并正在服药的儿童的常规随访(每年3-4次)。大多数(53.4%)临床医生还建议对被诊断为ADHD的儿童进行行为治疗。在治疗部分，专业差异的模式不太一致：儿科医生更有可能推荐药物治疗，但家庭医生报告说，对接受药物治疗的儿童进行更频繁的后续评估。行为疗法的推荐没有专业差异。除了医生专业的差异，执业类型和其他人口统计特征在管理上的差异也是明显的。医生对家长、教师或社区影响的态度与遵守指南部分之间几乎没有显著的关联。然而，许多受访者注意到了这些因素。只有32.5%的人同意他们的社区有足够的、可获得的精神卫生资源。一半(50.1%)的医生报告说保险公司限制了对ADHD的评估和治疗的承保范围。初级保健医生通常报告了解儿童ADHD指南，并遵循这些临床实践建议。然而，一些医生的差异是明显的，并指出了需要改进的领域。许多初级保健医生报告说，获得精神卫生服务的机会很少，保险覆盖范围有限，以及提供ADHD护理的其他潜在系统障碍。还需要更多的研究来确认提供者报告的数据；确定什么构成这种慢性病的高质量长期管理；以及确认报告的做法如何与ADHD儿童的长期结果相关联。
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 management 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 primary care physicians in Michigan. Main outcome measures 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 treatment. Bivariate and multivariate analyses were performed to assess patient and physician factors associated with adherence to guideline components.Results. The overall response rate was 60%. The majority (77.4%) of primary care physicians were familiar with AAP guidelines on ADHD, and many (61.1%) reported incorporating the guidelines into their practice. Differences were apparent by specialty: 91.5% of pediatricians were familiar with the guidelines in contrast to 59.8% of family physicians. The majority of clinicians reported practices consistent with individual components of the diagnostic and treatment guidelines. However, when adherence to multiple components was analyzed 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 modalities that are currently not recommended for routine evaluation of school-aged children with ADHD - continuous 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%) reported 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 management were apparent by practice type and other demographic characteristics. There were few significant associations 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 report awareness of pediatric ADHD guidelines and follow these clinical practice recommendations. However, some physician variations are apparent, and areas for improvement are noted. Many primary care physicians report poor access to mental health services, limited insurance coverage, and other potential system barriers to the delivery of ADHD care. Additional study is needed to confirm provider-reported data; to determine what constitutes high-quality, long-term management of this chronic condition; and to confirm how reported practices associate with long-term outcomes for children with ADHD.