The limited knowledge on the use of school-based telemedicine to improve follow-up care for ADHD in paediatric medicine was confronted by this three-phase, quality-improvement (QI) study. A school-based telemedicine intervention that includes visits occurring in the school with the individual’s primary medical home was used. The primary objective of this study was to increase the proportion of visits by 15% in 10 months for children and adolescents with ADHD (aged 5–18 years) who had follow-up within 30 days after a new diagnosis or medication change. This measure for telemedicine was compared with in-person visits to the Golisano Children’s Hospital Pediatric Practice, Rochester, NY, USA to assess whether telemedicine could offer more timely care for individuals with ADHD.
As part of the telemedicine intervention, three Plan-Do-Study-Act (PDSA) cycles were performed over a 12-month period. These QI interventions included education of clinicians and staff (PDSA 1), providing prompts for clinicians (PDSA 2) and developing a database of individuals with ADHD (PDSA 3).* The daily schedule for visits by individuals aged 5–18 years who were seen for well-child checks, behavioural concerns or ADHD follow-up was manually reviewed using a standardised chart review tool at least 3 months following the ADHD index visit. Data were collected on all ADHD-related visits. To maintain accuracy, a second individual reviewed 20% of charts manually. In total, 18 months of data between March 2018 and August 2019 were reviewed. Of the 2725 ADHD visits, 852 met criteria for stimulant medication initiation or a change in dose therefore requiring 30-day follow-up, representing 530 children.
Of the 530 children who met study criteria, 319 (60.2%) attended one subsequent visit, 137 (25.8%) attended two subsequent visits, 45 (8.5%) attended three, 21 (4.0%) attended four, and 8 (1.5%) attended five. Pre- (n=164) versus post–school-based telemedicine intervention (n=366) individuals were similar in age (mean [standard deviation; SD], 10.4 [3.0] years vs 10.1 [3.4] years) and gender (male population, 73.2% vs 74.9%) representation. The post-intervention sample included fewer individuals with private insurance than the pre-intervention sample (9.0% vs 15.9%). The proportion of visits meeting the 30-day follow-up goal increased from 18.8% (36/191) pre-intervention to 32.7% (216/661) post-intervention (risk ratio=1.73; 95% confidence interval [CI] 1.26–2.39; p=0.001). Clinician education appeared to improve follow-up for 3 months and, when it declined, initiation of a prompt followed by the initiation of the database appeared to increase follow-up within 30 days, with some fluctuations. To account for potential seasonal influences on the analysis, the proportions of follow-up visits carried out within 30 days were compared for March to August 2018 (18.8%, 36/191) and March to August 2019 (36.1%, 117/324), and a significant difference was found (risk ratio=1.92; 95% CI 1.37–2.69; p<0.001).
From the pre- to post-intervention periods, the time to follow-up decreased from 67 to 34 days (hazard ratio [HR]=1.95; 95% CI 1.34–2.83; p<0.001). Similarly, a significant decrease was seen when March to August 2018 was compared with March to August 2019 (67 to 32 days [HR=2.29; 95% CI 1.54–3.41; p<0.001]). Follow-up visits by telemedicine were also more likely to be within 30 days than visits conducted in person (61.7% vs 32.3%; risk ratio=1.91; 95% CI 1.56–2.33; p<0.001). The telemedicine follow-up visits also had fewer median days to follow-up (32 vs 48 days; HR=2.38; 95% CI 1.77–3.18; p<0.001). Overall, the number of ADHD visits increased from 134 visits per month pre-intervention to 160 visits per month post-intervention.
A limitation of this study was that the few individuals who did not have access to telemedicine visits in school could not be excluded from this analysis because data on school enrolment were not consistently collected. Another limitation is that the Golisano Children’s Hospital Pediatric Practice that was compared with for inpatient visits had less availability for in-person appointments within 30 days than via telemedicine, which may have inflated differences between the two modalities. Furthermore, individual clinician behaviour was not assessed, and data could not be collected for an entire 12-month baseline period due to an electronic health record upgrade. The generalisability and replicability of these results are limited due to the study being based in a single practice that relied heavily on a well-established school-based telemedicine programme.
Prior to this QI intervention, school-based telemedicine was seldom used in this practice for ADHD care. The authors of the study concluded that using a QI intervention with clinician education, prompts and database initiation improved guideline-based ADHD care for urban children; more individuals received follow-up within 30 days, and overall days to follow-up decreased significantly and were maintained as a result of school-based telemedicine.
*The QI intervention for PDSA 1 was a 20-minute multidisciplinary educational session for attending physicians, residents, nurse practitioners, child psychologists, therapists, nurse case managers, nurses and social workers. The intervention for PDSA 2 was a paper prompt which included information about availability of telemedicine for follow-up and the workflow to set up a telemedicine visit, which was attached to a parent Vanderbilt screen (Vanderbilt ADHD Diagnostic Rating Scale) for clinicians who were seeing individuals with ADHD. The intervention for PDSA 3 was the development of a database of individuals with ADHD using an electronic health record report, to capture individuals seen in the last year with an ADHD diagnosis. The team care coordinator was asked to review the database, contact individuals who were overdue for an ADHD appointment and schedule these visits.
Wenderlich AM, Li R, Baldwin CD, et al. A quality improvement initiative to improve attention-deficit/hyperactivity disorder follow-up rates using school-based telemedicine. Acad Pediatr 2021; Epub ahead of print.