Survey of United States child and adolescent psychiatrists' cardiac screening practices prior to starting patients on stimulants.
OBJECTIVE
The purpose of this study was to determine psychiatrists' barriers, attitudes, and practices regarding cardiac screening prior to initiating stimulants in children with attention-deficit/hyperactivity disorder.


BACKGROUND
Professional and federal oversight organizations recently have debated the evidence regarding sudden cardiac death (SCD) risk with stimulants, and have published guidelines recommending cardiac screening. It is not known how psychiatrists have responded.


METHODS
This study was a cross-sectional survey of 1,600 randomly-selected U.S. members of the American Academy of Child and Adolescent Psychiatry. Analyses included descriptive statistics and logistic regression.


RESULTS
Response rate was 40%; 96% met eligibility criteria. Barriers to identifying cardiac disorders in general included ability to perform a routine physical examination (74%) and care coordination with primary care providers (35%). Only 27% agreed that SCD risk warranted cardiac assessment. Prior to starting a patient on stimulants, 95% of psychiatrists obtained a routine history. The majority either conducted (9%), or relied on primary care providers to conduct (67%) a physical examination; 26% did not obtain a physical examination. Nineteen percent of psychiatrists ordered an electrocardiogram (ECG), of those, non-mutually exclusive reasons for ordering an ECG included standard practice procedure (62%), clinical findings (27%), medicolegal considerations (25%), and guideline adherence (24%). On multivariate modeling, psychiatrists were less likely to conduct cardiac screening themselves if in private practice (referent: academic medical center), if >50% of their patients had private insurance, or if they believed their ability to perform a physical examination to be a barrier. When modeling cardiac screening performed by any healthcare professional (e.g., psychiatrist, primary care practitioner), screening was less likely if the psychiatrist was practicing in a community mental health center (referent: academic medical center), was male, or if >50% of that psychiatrist's patients had private insurance.


CONCLUSIONS
Findings suggest the tacit interplay between primary care and psychiatry for the assessment and management of medical risks associated with psychotropic medications should be improved, and solutions prioritized.
The Institute of Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts 02111, USA. lleslie@tuftsmedicalcenter.org
Laurel K
LK
Leslie
Angie Mae
AM
Rodday
Tully S
TS
Saunders
Joshua T
JT
Cohen
John B
JB
Wong
R Christopher
RC
Sheldrick
Susan K
SK
Parsons
D000293:Adolescent; D000296:Adolescent Psychiatry; D000328:Adult; D001289:Attention Deficit Disorder with Hyperactivity / Q000150:complications / Q000188:drug therapy; D001291:Attitude of Health Personnel; D000697:Central Nervous System Stimulants / Q000009:adverse effects* / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D004562:Electrocardiography; D005260:Female; D019983:Guideline Adherence; D017408:Guidelines as Topic; D019538:Health Care Surveys; D006331:Heart Diseases / Q000175:diagnosis*; D006801:Humans; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D010818:Practice Patterns, Physicians'; D011570:Psychiatry; D018570:Risk Assessment; D014481:United States / Q000453:epidemiology
D000697:Central Nervous System Stimulants