In the UK, stimulant medications are the most frequently prescribed medications in the treatment of ADHD in children and adolescents. These drugs pose a risk of side effects, including a reduction in appetite, weight and potentially growth, as well as increased heart rate and blood pressure. For this reason, the 2008 UK National Institute for Health and Care Excellence guidelines and European ADHD guidelines recommend that physicians monitor the physical health of children prescribed stimulant medication for ADHD. The guidelines recommend a comprehensive baseline physical assessment including height, weight and blood pressure, reported as centiles and plotted on standardised growth charts, with subsequent monitoring throughout treatment. Despite this, the authors described the documentation of physical assessment at baseline as ‘poor and inconsistent’. They suggested that a shift from paper-based to electronic patient records may play a role in this, and aimed to determine if the use of a web-based app could improve compliance. To determine if this was in fact the case, the authors primarily looked at the proportion compliance of documenting centiles for blood pressure, height and weight, aiming for 75% over a 12-month period. As a secondary outcome, they investigated the monitoring of additional recommended physical assessments (heart rate, medical history, family history and, if indicated, electrocardiogram).
Following discussion with a multidisciplinary team,* the authors agreed that improvements to the process of calculating and documenting centiles would improve both reliability and efficiency for clinicians and subsequently may improve their recording compliance. As such, a web-based app was designed which both calculated the centiles of these observations as well as additionally providing the relevant text to be copied and pasted into the patients’ electronic medical records. The app was made freely available to all clinicians, with full training provided as part of an induction.† Baseline data were obtained from 41 randomly selected children or adolescents with ADHD who were prescribed stimulant medications within the 10 years following the introduction of electronic patient records. Subsequent data were obtained from all new ADHD assessments across three clinical teams from March 2015 to May 2016.
This quality-improvement project showed compliance of reporting centiles improved from 24% at baseline to 75% after 12 months. During the final 6 months, compliance was consistent and sustained, with 100% compliance indicating documentation of all three centiles at baseline in one case during one clinical encounter. Results of the secondary outcome measures showed an increase in median total proportion compliance from 58% at baseline to 83% after 12 months. The authors reported additional clinical benefits beyond these outcomes, such as prompt identification of elevated blood pressure leading to discussions regarding modifiable lifestyle factors such as smoking, diet and exercise, as well as aiding the clinicians’ prescribing decisions.
There were some limitations to this study. One such limitation is the relatively small sample size (n=33), which, when taken into account with variations in frequency of assessments effects and the resulting influence of each individual case, may describe the variability seen. Although an overall improvement was noted, potential factors which may affect use of a web-based app (such as limited computer access in clinic rooms) were not taken into account, so the effect of these cannot be determined.
Overall, the authors concluded that this quality-improvement project did improve the quality of physical health assessment in children and adolescents with ADHD, which represents a meaningful improvement in quality of care in the clinical service. Given the improvement in quality noted in this study, the authors also reported that they were in discussions to incorporate this web-based app into electronic medical records within the South London and Maudsley NHS Trust as a means to further improve quality, usability and sustainability. The app is freely available for use by others and can be accessed via: https://github.com/danwjoyce/centiles-shiny-app.git.
*The multidisciplinary team consisted of two consultant child and adolescent psychiatrists, four core psychiatry trainees, a clinical psychologist, a clinical nurse prescriber and a Foundation Year 1 doctor
†The study undertook two Plan-Do-Study-Act (PDSA) cycles. PDSA 1 introduced the web-based app to the three clinical teams involved, providing them with the required training and technical support. Following feedback, PDSA 2 began in October 2015 and included induction training for new staff, as well as additional training and problem-solving sessions to ensure maximum utility. The app was also made available on computers and mobile devices to further improve accessibility
Oxley C, Moghraby OS, Samuel R, et al. Improving the quality of physical health monitoring in CAMHS for children and adolescents prescribed medication for ADHD. BMJ Open Qual 2018; 7: e000213.