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9 Feb 2018

Hall CL et al. BMC Open 2018; 8: e021104

It is estimated that current treatment costs for ADHD medication in the UK amount to £78 million per year, and as the rate of ADHD diagnosis is increasing, this places a financial burden on healthcare systems and emphasises the importance of more efficient and cost-effective services to help diagnose and treat ADHD. The 2008 National Institute for Health and Care Excellence guidelines recommend that young people with ADHD should have access to the best evidence-based care and that regular monitoring of symptoms should occur. However, in practice, the delivery and quality of care for ADHD can be variable. Following commencement of ADHD medication, clinicians often rely on subjective information from parents and teachers together with their own observations to monitor symptom improvement; however, this can be an unreliable and difficult method to obtain information.

The development of the computer-based QbTest* may aid the objectivity, reliability and speed with which clinicians make decisions regarding ADHD medication. Qualitative evidence suggests that the QbTest can improve clinicians’ confidence in the diagnosis of ADHD before medication initiation, and has improved adherence to medication by reassuring children and young people with ADHD, and their families and teachers, of medication efficacy. Moreover, the QbTest has aided treatment decisions and dose-adjustment decisions, and has been shown to be sensitive to the effects of stimulant medications, which emphasises the potential clinical utility of the QbTest in managing ADHD medication. Despite these promising reports of the QbTest, few of these studies have been conducted in the UK, and most UK physicians still rely on clinical judgement and the traditional approach of using rating scales. Therefore, a formal evaluation of the role of the QbTest to aid medication control in ADHD is required to determine whether this test could become included in regular management of ADHD by healthcare services.

In line with the Medical Research Council guidance, the aim of the ‘QbTest Utility for Optimising Treatment in ADHD’ (QUOTA) study was to evaluate the feasibility and acceptability of a novel QbTest medication management protocol in a parallel-group, single-blind, feasibility randomised controlled trial (RCT). This trial will provide qualitative evaluation of the clinical utility of the protocol under standard practice conditions with treatment as usual (TAU) as the comparator. A total of 60 participants (aged 6–17 years) with ADHD and starting stimulant medication will be recruited to this study and will be randomised into one of two arms. In the experimental arm (QbTest protocol), participants will complete a QbTest prior to and at 2–4 weeks and 8–10 weeks following the initiation of medication. The clinician will use the QbTest scores to inform their clinical decision-making regarding medication decisions (i.e. to inform titration, drug choice or treatment switch/termination). In the control arm, participants will receive TAU with ≥2 follow-up consultations. At each consultation, global functioning and health-resource use, as well as parent-, teacher- and clinician-rated symptoms, will be assessed in all participants. Results from the QUOTA study will be used to inform the decision to initiate a fully powered, definitive RCT to investigate whether the QbTest can aid clinical decision-making and reduce the time it takes to reach an optimal ADHD medication dose, thereby improving health economics associated with ADHD.

Read more about the QUOTA study here


*The QbTest instructs a child or young person seated in front of a computer to use a handheld responder button to react to a predesignated, infrequent target stimulus that appears on-screen, whilst simultaneously withholding their response to other stimuli. The test takes approximately 20 minutes and provides a summary score relevant to each ADHD symptom domain of inattention, hyperactivity and impulsivity, with reference to an age- and gender-stratified normative database. Although the QbTest should not be used alone to make a decision regarding diagnosis and/or medication, it is hoped that it will provide another source of information for clinicians to aid decision-making and reduce the reliance on questionnaires

Hall CL, James M, Brown S, et al. Protocol investigating the clinical utility of an objective measure of attention, impulsivity and activity (QbTest) for optimising medication management in children and young people with ADHD ‘QbTest Utility for Optimising Treatment in ADHD’ (QUOTA): a feasibility randomised controlled trial. BMJ Open 2018; 8: e021104.

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