Improving patient care for uncomplicated ADHD in children and adolescents by organisational redesign and enhanced collaboration between psychiatry and general practice

Objective: This study aims to determine the effectiveness and efficiency of a program to implement prevailing guidelines for Attention Deficit Hyperactivity Disorder (ADHD) in children and adolescents (the 'ADHD-program'). Design: Cluster trial in 6 treatment teams at two sites, with a comperative before-after design. Patients in Nijmegen suspected of uncomplicated ADHD are selected from the group referred patients to our outpatient-clinic (n=3 treatment teams). The control-group consists of patients from the Karakter University Centre Zetten/Tiel outpatientclinic children and adolescent psychiatry (n=3 treatment teams). They receive care as usual. Study populations: Children and adolescents (6-15 year- olds) with uncomplicated ADHD and their parents. Their parents are involved in the study for reporting on symptom-monitoring, satisfactory experience and treatment adherence for medication and the parent-training component of the ADHD program. Professionals, such as General Practioners and the professionals of the Karakter Nijmegen Centre involved in this programme, comprise anothher study population. Intervention to be implemented: diagnostic and therapy, as recommended in the multidisciplinary ADHD guideline. Implementation intervention. The ADHD implementation program, which has been succesfully pilot tested in Nijmegen, focuses on children and adolescents with uncomplicated ADHD. It has two key components: organisational redesign at the mental health centre, so that time between referral and start of treatment is substantially reduced; and enhanced collaboration between psychiatry and general practitioners, by providing short courses for the GPs of referred patients. Sample size and statistical power. The study is powered to to detect a difference of 36 days in the time between referral to mental health centre and start of medical treatment. Taken into account clustering in the data, we aim to recruit a total of 162 patients (81 at each site, each with 3 teams who provide 27 patients). Data and outcome measures: The primary outcome is the time between referral to mental health centre and start of treatment. Data on this measures can be derived from the administrative data and the mental health centres. Secondary outcomes measured include: the functional status of the patients (measured by using the HoNOSCA), treatment adherence (measured by using the Morisky Adherence Scale, parents and patients satisfactory (using the Trimbos Thermometer), experiences of the GPs and professionals involved concerning the referral process and the GPs feeling of competence to prescribe and monitore medication for ADHD and the clinical indicator to monitor the ADHD symptoms before and after treatment by using the Conners Rating Scale (CRS-R). The economic evaluation is also taken into account to determine the effiency of the ADHD-programme. Sample size calculation/data analysis: A total of 180 patients will be included, 90 patients in the study group and 90 patients in the control group. Economic evaluation: Incremental cost effectiveness ratio's are determined of the implementation strategy compared to no implementation of the ADHD-program. The analysis will take a sociatal perspective and a time horizon of the observed period . Time schedule: Preparation of study including informing patients and involved professionals, organising sufficient instruments and facilities in Nijmegen en Groningen (month 1-2); Inclusion of patients (month 3-18), Measurement (month 9-24); Data-analysis and reporting (month 24-36).