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Distance-Learning, ADHD Quality Improvement in Primary Care: A Cluster-Randomized Trial

Fiks, Alexander G. MD, MSCE*,†,‡,§,‖; Mayne, Stephanie L. PhD, MHS*,†; Michel, Jeremy J. MD, MHS§,‖; Miller, Jeffrey MAS§; Abraham, Manju MS; Suh, Andrew BS*,†; Jawad, Abbas F. MSC, PhD**; Guevara, James P. MD, MPH*,†,‖,**; Grundmeier, Robert W. MD§,‖; Blum, Nathan J. MD††,‖; Power, Thomas J. PhD¶,‖

Journal of Developmental & Behavioral Pediatrics: October 2017 - Volume 38 - Issue 8 - p 573–583
doi: 10.1097/DBP.0000000000000490
Original Articles

Objective: To evaluate a distance-learning, quality improvement intervention to improve pediatric primary care provider use of attention-deficit/hyperactivity disorder (ADHD) rating scales.

Methods: Primary care practices were cluster randomized to a 3-part distance-learning, quality improvement intervention (web-based education, collaborative consultation with ADHD experts, and performance feedback reports/calls), qualifying for Maintenance of Certification (MOC) Part IV credit, or wait-list control. We compared changes relative to a baseline period in rating scale use by study arm using logistic regression clustered by practice (primary analysis) and examined effect modification by level of clinician participation. An electronic health record–linked system for gathering ADHD rating scales from parents and teachers was implemented before the intervention period at all sites. Rating scale use was ascertained by manual chart review.

Results: One hundred five clinicians at 19 sites participated. Differences between arms were not significant. From the baseline to intervention period and after implementation of the electronic system, clinicians in both study arms were significantly more likely to administer and receive parent and teacher rating scales. Among intervention clinicians, those who participated in at least 1 feedback call or qualified for MOC credit were more likely to give parents rating scales with differences of 14.2 (95% confidence interval [CI], 0.6–27.7) and 18.8 (95% CI, 1.9–35.7) percentage points, respectively.

Conclusion: A 3-part clinician-focused distance-learning, quality improvement intervention did not improve rating scale use. Complementary strategies that support workflows and more fully engage clinicians may be needed to bolster care. Electronic systems that gather rating scales may help achieve this goal. Index terms: ADHD, primary care, quality improvement, clinical decision support.

This article has supplementary material on the web site:

*Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA;

PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA;

Pediatric Research Consortium, Children's Hospital of Philadelphia, Philadelphia, PA;

§The Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA;

Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA;

Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA

**Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA;

††Division of Developmental and Behavioral Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.

Address for reprints: Alexander G. Fiks, MD, MSCE, Children's Hospital of Philadelphia, 3535 Market Suite, Room 1546, Philadelphia, PA 19104; e-mail:

This study was funded by a grant from Pfizer Independent Grants for Learning and Change. This study was also supported by Award Number K23HD059919 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The sponsors did not participate in the design or conduct of the study; data collection and analyses; interpretation of the data; or preparation, review, and final approval of the manuscript. In addition, the project was supported by the resources of the Pediatric Research Consortium of The Children's Hospital of Philadelphia.

Disclosure: A. G. Fiks, R. W. Grundmeier, J. J. Michel, and J. Miller are coinventors of the “Care Assistant” system described in this study. They hold no patent on the software and have earned no money from this invention. No licensing agreement exists. The remaining authors declare no conflict of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Clinical Trial Registration:, NCT02271386.

Received December , 2016

Accepted June , 2017

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