Reducing antipsychotic medication in ID using QI methodology

To measure the effect of implementing quality improvement (QI) methodology on the rate of chest radiograph (CXR) ordering for pediatric patients with acute asthma exacerbations.A total of 6680 pediatric patients age ≥2 years seen in the emergency department (ED) of a tertiary care children’s hospital for acute asthma were included in the study.Children ≥2 years old were retrospectively identified by chart review from May 2013 to April 2017. Included subjects had a primary International Classification of Diseases, Ninth Revision or 10th Revision billing code for asthma. An asthma clinical practice guideline (CPG) for CXR ordering in the ED was implemented in May 2014. Thus, the data from May 2013 to April 2014 were included as a 1-year baseline before intervention. Additional QI methods included removal of CXR as a default component of the electronic medical record asthma order set (July 2015), public reminder placement (January 2016), and targeted resident education (February 2016). The primary measure was CXRs ordered as a percentage of total acute asthma encounters, with a preintervention goal of <20%.A total of 1539 CXRs were ordered during 6680 patient encounters. Hospital-wide implementation of an asthma CPG was associated with a decrease in CXR use in acute asthma visits, from 29.3% to 23.0%. Implementation of targeted QI measures was associated with a further reduction in CXR use to 16.0%, which was sustained for 14 months (from February 2016 to April 2017). CXR use decreased from 21.3% to 12.5% in the subset of patients discharged from the hospital from the ED and from 53.5% to 31.1% among patients ultimately admitted to the hospital.Investigators in this study describe sustained reduction in CXR ordering in pediatric patients with acute asthma exacerbations after implementation of a CPG, later followed by QI interventions targeted at the electronic medical record system and at provider education.Old habits die hard. Previous studies have established that routine use of CXR in the evaluation of children with acute asthma exacerbations, the most frequent cause of childhood hospitalization in the United States, is of low diagnostic yield and is associated with significant risk, including unnecessary antibiotic administration. Despite evidence demonstrating low utility of CXR in this setting, implementation of “best” practice into clinical routine is challenging and can take years before change occurs. This study demonstrates how QI methodology can help break old habits, improve clinical care through patient-centered outcome measures, and most importantly, assist clinicians working in busy medical settings. It is impossible for any of us to stay current with the rapidly evolving world of medical knowledge. That is why dedicated use of QI methodology and commitment to changing culture can be so valuable.

The most severe forms of conduct disorder (CD) are disabling conditions, often resistant to treatment and likely to evolve into antisocial behaviours. Mood stabilizers and atypical antipsychotics are often used to treat severe cases of CD, as are antidepressants and psychostimulants less frequently, despite a relative lack of efficacy data. Use of lithium in hospitalized children and adolescents with CD has been evaluated in a small number of studies. To explore the efficacy and tolerability of lithium (administered either as monotherapy or in association with atypical antipsychotics) in children and adolescents with CD and to identify variables associated with positive or negative responses to such treatment. This retrospective study included 60 consecutive patients (46 males and 14 females; range 8-17 years; mean age 14.2 +/- 2.4 years) who were treated with lithium for CD diagnosed on the basis of the Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime (K-SADS-PL) clinical interview and the DSM-IV criteria for CD. The sample consisted of 44 inpatients (who remained in hospital during the first 2 or 3 weeks of treatment and were then assessed as outpatients) and 16 outpatients; the follow-up period was 6-12 months (mean 8.4 +/- 2.2 months). While all patients were initially treated with lithium, an atypical antipsychotic could be added if necessary to achieve satisfactory control of symptoms. Outcome measures included the Modified Overt Aggression Scale (MOAS), the Clinical Global Impression-Severity (CGI-S) and Clinical Global Impression-Improvement (CGI-I) scales, and the Aggression Questionnaire (which assessed the type of aggression, i.e. predatory vs affective). Patients were considered responders to pharmacological treatment at the end of the follow-up period if they satisfied all of the following criteria: >or=50% decrease in MOAS score, CGI-I score of 1 or 2 ('very much improved' or 'much improved') and CGI-S score of <or=3. Effect sizes were calculated for differences between pre- and post-treatment mean MOAS total and individual aggression dimension scores (an effect size >0.8 indicates good treatment efficacy). At the end of follow-up, 29 of 60 patients (48.3%) were classified as responders (10 receiving lithium monotherapy and 19 receiving lithium plus atypical antipsychotic therapy). For the sample as a whole, mean total MOAS score improved significantly (p < 0.001) and the effect size (pre- vs post-treatment) was 1.03. Mean MOAS verbal, and physical towards objects and other persons aggression scores, both in patients taking lithium as monotherapy and those also taking an add-on atypical antipsychotic, also improved significantly (p < 0.001) and the effect size was >or=0.80 for all items. Improvement in mean MOAS self-aggression score (p < 0.001) and an effect size of 0.59 was found when an atypical antipsychotic was added to lithium therapy. Predictors of a positive response to treatment were less severe disease at baseline, lower MOAS aggression scores and an impulsive (affective, nonpredatory) type of aggression. Gastrointestinal adverse effects, polydipsia and increased urinary frequency, tremor and increased thyroid stimulating hormone levels were the most frequently reported adverse effects. Two patients discontinued treatment because of adverse effects (vomiting and thyroid dysfunction). Lithium alone or in combination with an atypical antipsychotic may reduce aggressive behaviours in children and adolescents with CD. The adverse effects of such therapy are relatively common but rarely severe.

Attempts to estimate the cost effectiveness of attention-deficit hyperactivity disorder (ADHD) treatments in the past have relied on classifying ADHD patients as responders or non-responders to treatment. Responder status has been associated with a small gain in health-related quality of life (HR-QOL) [or utility, as measured using the generic QOL measure EQ-5D] of 0.06 (on a scale from 0 being dead to 1.0 being full health). The goal of the present study was to develop and validate several ADHD-related health states, and to estimate utility values measured amongst the general public for those states and to re-estimate utility values associated with responder status. Detailed qualitative interview data were collected from 20 young ADHD patients to characterize their HR-QOL. In addition, item-by-item clinical and HR-QOL data from a clinical trial were used to define and describe four health states (normal; borderline to mildly ill; moderately to markedly ill; and severely ill). ADHD experts assessed the content validity of the descriptions. The states were rated by 100 members of the UK general public using the time trade-off (TTO) interview and visual analog scale. Statistical mapping was also undertaken to estimate Clinical Global Impression-Improvement (CGI-I) utilities (i.e. response status) from Clinical Global Impression-Severity (CGI-S) defined states. The mapping work estimated changes in utilities from study baseline to last visit for patients with a CGI-I score of ≤ 2 or ≤ 3. The validity of the four health states developed in this study was supported by in-depth interviews with ADHD experts and patients, and clinical trial data. TTO-derived utilities for the four health states ranged from 0.839 (CGI-S state 'normal') to 0.444 (CGI-S state 'severely ill'). From the mapping work, the change in utility for treatment responders was 0.19 for patients with a CGI-I score of ≤ 2 and 0.15 for patients with a CGI-I score of ≤ 3. The present study provides utilities for different severity levels of ADHD estimated in a TTO study. This approach provides a more granular assessment of the impact of ADHD on HR-QOL than binary approaches employed in previous economic analyses. Change in utility for responders and non-responders at different levels of CGI-I was estimated, and thus these utilities may be used to compare health gains of different ADHD interventions.

BackgroundThe SCHEMA trial evaluates whether interpersonal art psychotherapy reduces the frequency/severity of aggressive incidents or patient distress associated with psychiatric symptoms, compared to usual care.ObjectiveTo describe the statistical and health economic analysis plan.MethodsA multicentre, two-arm, parallel-group, single blind individually randomised controlled trial with 150 adults within NHS secure care who have borderline to mild/moderate intellectual disability. The primary outcome is the frequency/severity of aggressive behaviour, measured on the Modified Overt Aggression Scale (MOAS) 19 weeks post-randomisation, analysed using a linear mixed-effect model, adjusted for baseline MOAS and stratification by gender and psychosis diagnosis. Changes in aggressive behaviour will be evaluated using weekly MOAS scores between 19 and 38 weeks. Patient distress relating to psychiatric symptoms will be assessed using the Brief Symptom Inventory Positive Symptom Distress Index across baseline, 19, and 38 weeks. Health-related quality-of-life will be assessed using self- and proxy-reported EQ-5D three-level (EQ-5D-3L) and Recovering Quality of Life 10-item measures, the latter to estimate the ReQoL Utility Index, across baseline, 19, and 38 weeks. The self-reported EQ-5D-3L is collected using an adapted version for people with intellectual disabilities. Resource-use is collected based on secure care records, to estimate intervention and healthcare costs over 19 and 38 weeks. HRQoL and cost data will inform cost-effectiveness based on the incremental cost per quality-adjusted life year over 38 weeks.DiscussionThis paper details the planned analyses and discusses recruitment challenges, sample size implications, and effect size assumptions. The plan was developed prior to database lock and unblinding to minimise analytical bias.Trial registrationISRCTN, ISRCTN57406593. Registered on 18/01/2023.

Mechanical ventilation supports patients with respiratory failure during critical illness. Evidence suggests that excessive tidal volumes (regarded as >8 mL/kg predicted body weight [PBW]) cause lung damage through increased lung stretch and alveolar inflammation. Lung-protective ventilation strategies have been shown to decrease morbidity and mortality, and that all patients should receive tidal volumes between 6 and 8 mls/kg PBW. Despite this, studies demonstrate that fewer than half of patients in critical care successfully receive lung-protective ventilation. The primary aim was to reduce tidal volumes delivered to all patients receiving mandatory ventilation, with a target of >85% of tidal volumes delivered to be compliant with lung-protective ventilation strategies by the end of November 2019. A multidisciplinary team of nurses and doctors, based in a UK tertiary hospital, utilized the Institute for Healthcare Improvement's (IHI) quality improvement methodology to improve compliance with lung-protective ventilation. Baseline data demonstrated that only 60.1% of tidal volumes recorded were compliant with lung-protective ventilation. Quality improvement (QI) methodology was utilized to systematically diagnose the aetiology of poor compliance and to produce and implement solutions. Real-time data collection and reporting were utilized to monitor and report improvement. Following 8 months of continuous data collection and repeated PDSA cycles, sustainable compliance with lung-protective ventilation for >85% of tidal volumes was achieved. The use of QI methodology to implement low tidal volume ventilation has shown a significant improvement in the delivery of lung-protective ventilation. Using QI methodology is central to this sustained improvement and offers a useful tool to systematically approach complex clinical problems. Lung protective ventilation is critically important in the management of ventilated patients, although compliance in intensive care is variable. Here, we describe how quality improvement methodology can lead to consistent and sustainable improvement in the delivery of lung protective ventilation.

PurposeAttention deficit hyperactivity disorder (ADHD) in adults is one of the psychological problems that can increase the risk of accidents and trauma, especially head trauma. Recent studies have reported the frequency of adult attention deficit hyperactivity disorder (ADHD) among trauma patients. Adult AD0HD has been reported in trauma patients. In the present study, we hypothesized that adult ADHD was more common among head trauma patients following an accident compared to a group without trauma.Materials and MethodsIn this case-control study, 230 patients with head injuries and 460 non-trauma patients were selected. The adult Connors self-report screening scale (CAARS-SV) was used to screen for ADHD. Three subscales as subscale A (attention deficit index), subscale B (hyperactivity index) and subscale D (ADHD index) were evaluated between the two groups. Using linear multiple regression analysis, the effect of group, age, gender, and socioeconomic variables on ADHD scores was evaluated.ResultsThe total frequency of adult ADHD was 9.5%, which was equal to 1.6% in the trauma group and 9.5% in the non-trauma group. The experimental group had more drivers as the job (11.7% vs 3.7%, P<0.001) compared to the control group. Of the Connors subscales, only the D subscale was significantly lower in the case group than in the control group (6.35 6 5.11 vs 51.72 4 72.4, P=0.003). The prevalence of ADHD in patients with head trauma and non-trauma head injury was 6.1% and 5.9%, respectively, which did not show a statistically significant difference (P=0.9). Linear regression analysis showed that the subscale D only had a significant relationship with group and age. However, by entering variables in logistic regression analysis, it was observed that only the age variable was significant in the presence of other variables.ConclusionAccording to the results of the present study, the frequency of adult ADHD in trauma patients, as a screening diagnosis, was not found to be higher than non-traumatic patients.

Although the relationship between attention-deficit/hyperactivity disorder (ADHD) and transport accidents has been shown, there is limited information on the relationship between medication and dose-response effects and transport accident risk. This study aims to determine whether young people with ADHD, including adolescents, are more prone to transport accidents than those without, and the extent to which methylphenidate (MPH) prescription in these patients reduces the risk. We identified 114 486 patients diagnosed with ADHD from Taiwan's National Health Insurance Research Database from 1997 to 2013. Using a Cox regression model, we compared the risk of transport accidents between ADHD and non-ADHD groups and estimated the effect of MPH on accidents. Furthermore, we applied a self-control case-series analysis to compare the risk of accidents during the medication periods with the same patients' non-medication periods. Male ADHD patients had a higher risk of transport accidents than non-ADHD individuals (adjusted hazard ratio [aHR] = 1.24, [95% confidence interval (CI) 1.10-1.39]), especially for those comorbid with epilepsy, oppositional defiant disorder/conduct disorder (ODD/CD), and intellectual disabilities (ID). Female ADHD patients showed no relationship, except for comorbid with autism spectrum disorder (ASD) or ID. We found a reduced risk of transport accidents in patients with ADHD with MPH medication than those without MPH, with a plausible dose-response relationship (aHR of 0.23 to 0.07). A similar pattern was found in self-controlled case-series analysis. Male patients with ADHD, especially those comorbid with epilepsy, ODD/CD, or ID, were at high risk of transport accidents. Female patients, when comorbid with ASD or ID, also exhibited a higher risk of accidents. MPH treatment lowered the accident risk with a dose-response relationship.

Introduction ADHD causes significant distress and functional impairment in multiple domains of daily life. Therefore, diagnosis and treatment are important to improve the quality of life of people. The pharmacotherapy for ADHD is well established but needs systematic evaluation in Intellectual Disability (ID) populations. Areas covered This paper reviews the ADHD pharmacological treatment in people with ID using the PRISMA guidance for scoping reviews to help identify the nature and strength of evidence. Expert opinion In the last 20 years, seven randomized controlled trials have evaluated pharmacotherapies for ADHD in people with ID; five looking at methylphenidate. Generally, studies were underpowered; all but two had less than 25 participants. Of the two larger trials one was single blinded and therefore open to bias. Only two used a parallel-group method, the remainder were mostly short crossover trials; not ideal when measuring behavioral and psychological parameters which are long standing. The remaining evidence is made up of observational studies. Methylphenidate and atomoxetine, particularly at higher doses, have shown clear benefits in people with ID. Most people with ID tolerated ADHD medications well. Benefits were seen in behavioral and/or cognitive domains. The evidence base is limited, though promising, for dexamfetamine, clonidine, and guanfacine.

The present study focuses on selected symptom criteria to distinguish between attention deficit/hyperactivity disorder (ADHD) in adults and borderline personality disorder (BPD). A sample of n = 158 subjects was examined, consisting of BPD patients (n = 37), ADHD patients (n = 58), comorbid BPD/ADHD patients (n = 19), a clinical group of patients fulfilling the diagnostic criteria of a depressive disorder (DEP; n = 22) and a non-clinical control group (KG; n = 22). Selected symptom criteria were investigated by using the German scales "Skala zur Erfassung der Impulsivität und emotionalen Dysregulation der Borderline-Persönlichkeitsstörung" (IES-27), "ADHS-Screening für Erwachsene" (ADHS-LE), "Fragebogen zu dissoziativen Symptomen" (FDS) and a scale for the assessment of paranoid and dichotomous thinking (PADI). Multivariate analyses of variance revealed that BPD patients differed significantly with respect to self-mutilating behaviour, suicidality, dissociation, paranoia and dichotomy from all other groups. The same effect was found for affect regulation. Furthermore BPD patients differed significantly from ADHD patients by a more severe impulsiveness (IES-27), but not through disturbed impulse control and disinhibition overall. Regarding mean differences between ADHD and BPD patients for attentional control, ADHD patients revealed higher scores which just missed significance. For hyperactivity no significant group differences were found which is assumed to be influenced by symptom overlap like restlessness and aversive tension. The findings suggest that BPD-specific criteria, a stronger affective dysregulation and a higher tendency for autoaggressive impulsive reactions are more selective for differential diagnosis than the core symptoms of adult ADHD. Only attentional control might be a useful criterion for differential diagnosis, which should be examined in future studies.

BackgroundAttention deficit hyperactivity disorder (ADHD) frequently co-occurs with substance use disorders (SUD). The combination of ADHD and SUD is associated with a negative prognosis of both SUD and ADHD. Pharmacological treatments of comorbid ADHD in adult patients with SUD have not been very successful. Recent studies show positive effects of cognitive behavioral therapy (CBT) in ADHD patients without SUD, but CBT has not been studied in ADHD patients with comorbid SUD.Methods/designThis paper presents the protocol of a randomized controlled trial to test the efficacy of an integrated CBT protocol aimed at reducing SUD as well as ADHD symptoms in SUD patients with a comorbid diagnosis of ADHD. The experimental group receives 15 CBT sessions directed at symptom reduction of SUD as well as ADHD. The control group receives treatment as usual, i.e. 10 CBT sessions directed at symptom reduction of SUD only. The primary outcome is the level of self-reported ADHD symptoms. Secondary outcomes include measures of substance use, depression and anxiety, quality of life, health care consumption and neuropsychological functions.DiscussionThis is the first randomized controlled trial to test the efficacy of an integrated CBT protocol for adult SUD patients with a comorbid diagnosis of ADHD. The rationale for the trial, the design, and the strengths and limitations of the study are discussed.Trial registrationThis trial is registered in http://www.clinicaltrials.gov as NCT01431235.

Other than in children diagnosed with attention deficit hyperactivity disorder (ADHD), the connection between ADHD and lipids has not been sufficiently investigated so far in adults. Blood serum lipoproteins and fatty acids (FA) composition were measured and analyzed by colorimetry and gaschromatography in eight male and seven female adults diagnosed with ADHD as well as in 15 age- and gender-matched healthy control subjects. In ADHD patients, polyunsaturated FAs [docosahexaenoic, arachidonic and dihomogammalinolenic acid (p = 0.048; 0.003; 0.012)] showed lower concentrations, while monounsaturated acids (palmitoleic and oleic acid) as well as total and LDL cholesterol showed higher concentrations (p = 0.011; 0.005). ADHD scores positively correlated with palmitoleic (R = -0.56; p = 0.032), stearic (R = 0.53; p = 0.044), eicosapentaenoic (R = 0.62; p = 0.014), docosahexaenoic (R = 0.51; p = 0.050), gammalinolenic (R = 0.62; p = 0.018) and alphalinolenic acid (R = 0.56; p = 0.031) concentration. Even though the total and LDL cholesterol concentrations in blood serum were significantly higher among the ADHD patients than in controls, none of the ADHD symptom scores were significantly associated with any of the lipoproteine measures. We could demonstrate that a lack of polyunsaturated FAs in blood serum of subjects with ADHD persists into adulthood. Furthermore, we could show that adult ADHD symptomatology positively correlates with elevated levels of saturated stearic and monounsaturated FAs.

[This corrects the article on p. 151 in vol. 6, PMID: 26557098.].

Clinical and electroencephalographic features of benign childhood epilepsy with centrotemporal spikes comorbidity with attention-deficit hyperactivity disorder in Southwest China

Impaired flexible reward learning in ADHD patients is associated with blunted reinforcement sensitivity and neural signals in ventral striatum and parietal cortex

Editorial: Introduction to Special Section on Evidence-Based Practices for Persons With Intellectual and Developmental Disabilities