Adding care management to treatment plan does not significantly improve attention-deficit/hyperactivity disorder symptoms

by Molly Munsell, Alex Gipsman, MD

Originally published by 2 Minute Medicine® (view original article). Reused on AccessMedicine with permission.

1. In a small randomized controlled trial of children with attention-deficit/hyperactivity disorder (ADHD), symptoms did not differ between patients assigned to a care manager in addition to a patient portal compared to patient portal alone.

2. ADHD symptom scores decreased significantly over 9 months in the entire study population.

Evidence Rating Level:1 (Excellent)

Study Rundown:

Attention-deficit/hyperactivity disorder (ADHD) is an increasingly common childhood neurobehavioral disorder. Treatment of ADHD may include medication, behavioral therapy, and school-based interventions. This multimodal approach often leads to challenges in adherence and care coordination. Use of an electronic health record-associated patient portal designed to facilitate communication between clinicians, parents, and teachers has been found to improve outcomes in a previous randomized controlled trial (RCT). In this study, 303 patients at 11 primary care practices were randomized to two treatment groups: care management and patient portal versus patient portal alone. Care managers provided ADHD education, elicited treatment goals and monitored attainment, and attempted to contact families, teachers, and clinicians at least every 3 months. In both groups, there was a significant decrease in ADHD symptoms over time as measured using Vanderbilt Parent Rating Scale (VPRS) scores. This decrease was greater in children on medication. However, there was no difference in change in VPRS scores between the two groups over the 9-month study. This study suggests that there is not a clinically significant benefit to assigning a care manager for ADHD patients in settings where formal communication tools have already been implemented. However, it does not speak to the role of care management compared to no intervention.

In-Depth [randomized controlled trial]:

This comparative effectiveness study recruited patients from 11 urban and suburban primary care practices in one metropolitan area. Children aged 5 to 12 with ADHD were included. Participants were stratified by pediatric practice, sex, and age group, then randomized to receive either care management alongside access to an ADHD-specific patient portal linked to the electronic health record or portal access alone. The primary outcome was change in the symptom subscale of the VPRS score, measured at 4 study visits during the 9-month study period. Only 68% of all patients’ caregivers used the portal to complete a VPRS over the study period, and only 30% had a teacher use the portal for at least one session. Engagement with care managers was somewhat higher, with 96% of participants in the treatment group receiving at least one session, although the mean number of sessions was only 2.2. In the full linear model, the intervention-by-time interaction was not significant (β = 0.00, p = 0.975), meaning that ADHD symptom scores did not change differently between the two treatment groups. In both groups, VPRS scores over the treatment period (p < 0.001). Medication status was associated with significantly lower symptom scores, while children who lived in urban areas had significantly higher scores. In a within-group sensitivity analysis, patients who received at least 2 care management sessions had a greater decrease in VPRS score (-4.7, 95% confidence interval -8.0 to -1.4) than those who had one or no sessions, suggesting a dose-response to care management.

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