The Study and The Real World

In Office Visits and ADHD Meds, yesterday’s post at Spotlight On ADHD, Dr. Brian Doyle points to a study¹ which he finds unsettling because of the implications its findings would have for practices treating these patients.

The only summary of the study I was able to find online this morning was in New and Emerging Data in the Management of ADHD, the source of these excerpts:

From this data, the researchers postulated “a direct relationship between the number of office visits and the number of prescriptions filled, suggesting a positive link between office follow-up and compliance” and suggested that “more frequent
office follow-up may lead to improved medication adherence among patients with ADHD.”

Dr. Doyle’s concerns are summarized in this excerpt from his post:

Commentary

First, in the spirit of full disclosure, I should clarify that

1. When I was involved in office practice, I treated batches of ADHD kids (although, I suspect, not as many as Dr. Doyle does) and my scheduling protocol for ADHD adolescents was almost precisely identical to his. Once the patients were stabilized, I would routinely see them once every three months for 15-30 minutes unless there was a specific problem that required more time or more frequent visits (this was a rarity). Almost all the ADHD patients I treated with medication were seen more often by a non-psychiatric therapist. I saw patients every three months because that’s how the psychiatrists I knew handled patients taking AHDH medication.
2. I am also the parent of an ADHD child who was on medication for several years. In treatment with four or five different pediatricians and psychiatrists over the years, he was almost always seen for medication check-ups once every three months for 15-30 minutes.

Given my clinical and family background, I may well be reacting defensively. Nonetheless, until I know some details of the study that are currently unavailable to me, I’m unable to generate much angst about my previous practices or enthusiasm to promote the idea that “more frequent office follow-up may lead to improved medication adherence among patients with ADHD.”

Some of the pertinent questions about the research, it seems to me, include the following:

• Was the frequency of patient visits a function of the specific case (i.e., did the clinicians in the study vary how often they requested visits by the difficulty of the case), the clinician (i.e., did some clinicians routinely schedule visits more often than others such that frequency of visits was a proxy for different groups of clinicians), or the patient and family (i.e., did the patients who did not show up at the office as often miss scheduled appointments)?
• Did the frequency of visits vary with the course of treatment (i.e., given that the patients were all “newly diagnosed,” did the clinicians use the same paradigm Dr. Doyle and I used, seeing the patient frequently at first and then decreasing the frequency)?
• What proportions of the patients fell in each age group and how did frequency of visits correlate to age (e.g., were young children routinely seen more frequently so compliance might have varied by age rather than frequency)?
• Did the clinicians provide prescriptions at times other than office visits?

Because such variables could clearly affect the suggestion that increased frequency of visits could increase compliance with medication, I suspect that some or all of them have been addressed, but until I review that information, I would hesitate to make further scheduling demands on the patients who are doing well (and their parents) based on these findings.

Footnotes

1. Hodgkins P, Boken M, Capone NM, et al: Office visits and prescription fill rates in patients with ADHD. Poster 119, presented at the 19th Annual US Psychiatric and Mental Health Congress; November 16, 2006; New Orleans, LA. [back]

• A Pragmatic Consideration Of Noncompliance In Patients With (Or Without) ADHD
• Study Shows No Correlation Between Dosing Frequency and Medication Compliance
• Results Of Differing Methods Of Communicating Treatment Benefits To Patients
• Aligning The Interests Of Uninsured Patients And The Hospitals That Care For Them
• Patient Adherence And Prevention Of Nontraumatic Amputations