Blue Care Network Best Practices
Attention deficit hyperactivity disorder
Follow-up visits critical for patients with attention deficit hyperactivity disorder
One of the HEDIS measurements requires that physicians who prescribe medication for attention deficit and hyperactivity disorder schedule follow-up visits with the patient 30 days after the initial prescription and then two additional follow-up visits during the continuation phase. But some doctors prefer more frequent visits to better track their patients’ progress.
"We follow up more frequently so we can check for side effects and how behavior modifications are working," says Lynn Gessner, M.D., a partner at The University of Michigan Brighton Health Center. "We also check with parents about how things are going at home and in school."
Patients with ADHD comprise approximately 5 to 10 percent of the practice, so it’s important to have high compliance rates. One of the things Dr. Gessner uses to help with patient compliance is a Patient Responsibility Agreement. "It just puts in writing our policies." The practice schedules follow-up visits every three months, as well as an annual physical. The first follow-up visit after the initial prescription is generally three weeks. The responsibility agreement outlines the timetable of the visits and lets patients and their parents know when to notify the office when they need refills and not to share their medication with anyone.
Since stimulant medications are controlled substances, there are pharmacy rules about how the medications can be dispensed, Dr. Gessner explains. "We can’t just call in a prescription so we ask for at least two business days when a refill will be required."
Having a group protocol as part of the University of Michigan also helps focus the follow-up visits. Dr. Gessner spends a lot of time doing screening at the beginning of each school year. "I want to assess the patient at the beginning of the year to see if the medication is still working the same as when the last school year ended," she explains.
At the first visit of the school year, Dr. Gessner will often have new forms distributed to teachers so they can record their observations about the patient. New forms are also distributed every time Dr. Gessner changes the medication or dosage.
Follow-up visits are also a good time to review behavior modification strategies. Strategies are individualized for each patient after doctor and parents brainstorm together. Dr. Gessner also gives parents outside resources, such as the American Academy of Pediatrics website healthychildren.org which has ADHD education and resources.
The cooperation of the family is important to the patient, Dr. Gessner says. "As a pediatrician, I sometimes just see a mom or dad come to the visit. This is one of the times I like both parents to be available. I want everyone caring for the child on the same page."
Generally, pediatricians can manage a straightforward ADHD diagnosis, says Dr. Gessner. But she will also refer a patient to a psychiatrist if the patient is not responding to treatment. "Sometimes it’s a one-time referral for a diagnosis and guidance and other times, the patient needs more formal therapy for comorbidities, such as depression or anxiety," says Dr. Gessner. "You need to make sure you are treating the right diagnosis."
Dr. Gessner doesn’t take lightly putting a child on stimulant medication. When used properly, medication is safe. But Dr. Gessner points out that the most challenging aspect of treating children with ADHD is the initial diagnosis.
"It’s critical that we make an appropriate diagnosis and do not inaccurately diagnose ADHD before we begin medication," she said. "If you have a comorbidity such as depression, you don’t want to treat the wrong thing. That’s the hardest part. Making sure I feel comfortable taking ownership of that patient’s diagnosis and treatment."
For follow-up visits at the end of the school year, Dr. Gessner evaluates whether her patients need their medication during the summer months. "Some kids function well without medication and can take a break in the summer if they are mostly being treated for school difficulties," she said. "Others need medication to improve their interaction with siblings and parents or for participation in sports activities. The decision is very personal for kids and their families."
Although ADHD is a chronic condition, we don’t always need to treat it, she says. "Some patients develop in their maturity and their ability to redirect themselves."