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Quality of Care for Childhood Attention-Deficit/Hyperactivity Disorder in a Managed Care Medicaid Program

https://doi.org/10.1016/j.jaac.2010.08.012Get rights and content

Objective

To examine whether clinical severity is greater among children receiving attention-deficit/hyperactivity disorder (ADHD) care in primary care compared with those in specialty mental health clinics, and to examine how care processes and clinical outcomes vary by sector across three 6-month time intervals.

Method

This was a longitudinal cohort study of 530 children aged 5 to 11 years receiving ADHD care in primary care or specialty mental health clinics from November 2004 through September 2006 in a large, countywide managed care Medicaid program.

Results

Clinical severity at study entry did not differ between children who received ADHD care in solely primary or specialty mental health care clinics. At three 6-month intervals, receipt of no care ranged from 34% to 44%, and unmet need for mental health services ranged from 13% to 20%. In primary care, 80% to 85% of children had at least one stimulant prescription filled and averaged one to two follow-up visits per year. Less than one-third of children in specialty mental health clinics received any stimulant medication, but all received psychosocial interventions averaging more than five visits per month. In both sectors, stimulant medication refill prescription persistence was poor (31%–49%). With few exceptions, ADHD diagnosis, impairment, academic achievement, parent distress, and parent-reported treatment satisfaction, perceived benefit, and improved family functioning did not differ between children who remained in care and those who received no care.

Conclusion

Areas for quality improvement are alignment of clinical severity with provider type, follow-up visits, stimulant use in specialty mental health, agency data infrastructure to document delivery of evidence-based psychosocial treatment, and stimulant medication refill prescription persistence.

Section snippets

Study Population

The study population comprised children aged 5 to 11 years who were identified by the agency as receiving any ADHD care in a large managed care Medicaid program in primary or specialty mental health care outpatient settings between January 1, 2003, and June 30, 2004. The health plan serves nearly 750,000 County of Los Angeles residents of all ages enrolled in managed care Medicaid, and specialty mental health services are carved-out to the County of Los Angeles Department of Mental Health (DMH).

Sociodemographic Characteristics

The average child age was 9.9 years (SD, 1.9), 68% were male (n = 370), and most (n = 474, 87%) were from minority racial or ethnic backgrounds. Nearly one quarter (n = 125, 23%) were African-American, 54% (n = 293) were Latino, 13% (n = 72) were Caucasian, and 10% (n = 56) were reported by their parents as being from two or more ethnic backgrounds or from other ethnic groups. Of the Latino children, 75% (208/277, 16 missing data) were in the family's first U.S. born generation. Of the parents,

Discussion

Care for childhood ADHD in the managed care Medicaid program studied failed to meet the Institute of Medicine's definition of quality that requires “consistency with current professional knowledge” and “improved likelihood of desired health outcomes.”2 More than one-third of children were receiving no care when interviewed at baseline, a rate double the national rate for adults.38 Despite similar clinical severity, treatment approaches for children were strikingly different in primary care and

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    This study was supported by the National Institute of Mental Health (RO1 MH061540, P30 MH068639, and P30 MH082760).

    Disclosure: Dr. Bussing is a consultant to or receiving honoraria from Eli Lilly and Co., and Shire, and receives research support from Forest, Pfizer Inc, and Shire. Drs. Zima, Tang, Ettner, Belin, Wells, and Ms. Zhang report no biomedical financial interests or potential conflicts of interest.

    This article is discussed in an editorial by Dr. Mark Olfson on page 1183.

    Supplemental material cited in this article is available online.

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    Copyright © 2010 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.