title: Variability in ADHD care in community-based pediatrics.
abstract: BACKGROUND
  Although many efforts have been made to improve the quality of care delivered to children with attention-deficit/hyperactivity disorder (ADHD) in community-based pediatric settings, little is known about typical ADHD care in these settings other than rates garnered through pediatrician self-report.
  
  
  METHODS
  Rates of evidence-based ADHD care and sources of variability (practice-level, pediatrician-level, patient-level) were determined by chart reviews of a random sample of 1594 patient charts across 188 pediatricians at 50 different practices. In addition, the associations of Medicaid-status and practice setting (ie, urban, suburban, and rural) with the quality of ADHD care were examined.
  
  
  RESULTS
  Parent- and teacher-rating scales were used during ADHD assessment with approximately half of patients. The use of Diagnostic and Statistical Manual of Mental Disorders criteria was documented in 70.4% of patients. The vast majority (93.4%) of patients with ADHD were receiving medication and only 13.0% were receiving psychosocial treatment. Parent- and teacher-ratings were rarely collected to monitor treatment response or side effects. Further, fewer than half (47.4%) of children prescribed medication had contact with their pediatrician within the first month of prescribing. Most variability in pediatrician-delivered ADHD care was accounted for at the patient level; however, pediatricians and practices also accounted for significant variability on specific ADHD care behaviors.
  
  
  CONCLUSIONS
  There is great need to improve the quality of ADHD care received by children in community-based pediatric settings. Improvements will likely require systematic interventions at the practice and policy levels to promote change.
authors.affiliation: Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; jeff.epstein@cchmc.org.
authors.forename: Jeffery N
authors.initials: JN
authors.lastname: Epstein
authors.affiliation: Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio;
authors.forename: Kelly J
authors.initials: KJ
authors.lastname: Kelleher
authors.affiliation: Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio;
authors.forename: Rebecca
authors.initials: R
authors.lastname: Baum
authors.affiliation: Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio;
authors.forename: William B
authors.initials: WB
authors.lastname: Brinkman
authors.affiliation: Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio;
authors.forename: James
authors.initials: J
authors.lastname: Peugh
authors.affiliation: Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio; Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada;
authors.forename: William
authors.initials: W
authors.lastname: Gardner
authors.affiliation: The Children's Home of Cincinnati, Cincinnati, Ohio; and.
authors.forename: Phil
authors.initials: P
authors.lastname: Lichtenstein
authors.affiliation: Department of Psychology, Virginia Commonwealth University, Richmond, Virginia.
authors.forename: Joshua
authors.initials: J
authors.lastname: Langberg
mesh_terms: D001289:Attention Deficit Disorder with Hyperactivity / Q000628:therapy*; D000697:Central Nervous System Stimulants / Q000627:therapeutic use; D002648:Child; D003156:Community Mental Health Services; D004505:Education, Nonprofessional; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D008297:Male; D008484:Medicaid; D010372:Pediatrics; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians'; D011613:Psychotherapy; D011785:Quality Assurance, Health Care; D058996:Quality Improvement; D012189:Retrospective Studies; D019035:Rural Health Services; D019036:Suburban Health Services; D014481:United States; D019037:Urban Health Services
chemical_list: D000697:Central Nervous System Stimulants
keywords: attention deficit and disruptive behavior disorders; behavioral medicine; guidelines; pediatrics; quality