Evaluating a Web-based Adult ADHD Toolkit for Primary Care Clinicians

Natalia Y. Loskutova, MD, PhD; Cory B. Lutgen, BS; Elisabeth F. Callen, PhD, GStat; Melissa K. Filippi, PhD, MPH; Elise A. Robertson, MA

Disclosures

J Am Board Fam Med. 2021;34(4):741-752.

Abstract and Introduction

Abstract

Introduction: Approximately 5% of the US adult population has Attention Deficient Hyperactivity Disorder (ADHD) that can negatively impact quality of life. Health care professionals report a need to increase their knowledge of and confidence in treating adult ADHD. The American Academy of Family Physicians National Research Network (AAFP NRN) collaborated with a panel of experts to create a web-based AAFP Adult ADHD Toolkit composed of resources to aid in the diagnosis, management, and treatment of adults with ADHD.

Objectives: Assess the impact of using an AAFP Adult ADHD Toolkit in a practice setting.

Methods: Ninety-seven primary and behavioral health care professionals from AAFP NRN practices (n=6) used the Toolkit for 17 weeks. Data on Toolkit use, usefulness, implementation, impact, and changes in knowledge and confidence were collected via pre-post and weekly surveys. Mixed methods, regression analyses, t-tests, and mixed ANOVA were used to assess change over time.

Results: Use of the Toolkit improved health care providers' knowledge by midpoint relative to baseline in areas related to treatment effects, side effects, and outcomes (3.6 vs 3.0; P = .004); existing ADHD resources (3.3 vs 2.9; P = .03); and management of ADHD in patients with comorbid conditions (3.2 vs 2.7; P = .01). By the end of the study, Toolkit use was associated with increased confidence in mental health and life history interview techniques (3.5 vs 3.0; P = .03); treatment options for ADHD with comorbid mental health disorders (3.2 vs 2.3; P ≤ .001); and treatment options for ADHD with coexisting substance use disorders (3.0 vs 2.3; P = .003). By the end of the study, most participants (n=47, 87%) reported the Toolkit addressed most of their needs related to diagnosis, treatment, and management of adult ADHD.

Conclusion: Availability and adoption of the Toolkit into the routine care of adults with ADHD measurably increased health care professionals' knowledge especially in those providers who regularly see adult patients with ADHD.

Introduction

Attention deficit hyperactivity disorder (ADHD) is a prevalent condition in both children and adults, affecting about 5% of the adult population. Primary Care Practitioners (PCPs) are usually the first clinicians to be in contact with adults affected by ADHD. PCPs receive little training for diagnosing and treating adult ADHD and know little about the comparative effectiveness and cost-effectiveness of the diagnostic and treatment options for this disorder. Previous studies reported a low level of competence in diagnosing ADHD in adults, poor familiarity with existing diagnostic criteria, low awareness of existing provider and patient resources, and deficiencies in evidence-based medication treatment decisions for adults with ADHD among PCPs.^[1–4] Many family physicians reported they prescribe stimulants based on their own success, comfort level, and clinical judgment rather than evidence-based guidelines.^[5] This is not surprising, as there are no evidence-based primary care-focused treatment algorithms and practice guidelines for adult ADHD in the United States. While adult ADHD resources for physicians and patients exist, there is no comprehensive, accurate, and easily accessible "one-stop shop" resource on adult ADHD. PCPs report a need to increase their knowledge of the disorder and confidence in diagnosing and managing ADHD in adults through education, tools, and resources.

To address this need, we sought to use the consensus-based participatory approach to develop and evaluate a toolkit for facilitating comprehensive care for adults with ADHD. The evaluation was designed to assess the implementation of the toolkit in routine clinical care with minimal outside intervention. The objectives of this article are to report on (a) the methods used in toolkit development, and (b) the results of implementation and evaluation on provider-level outcomes (knowledge, attitudes, and practice/behavior), use, and perceived value of the toolkit.

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Next Section

Abstract and Introduction
Methods
Results
Discussion
Conclusions
References

Table 1. Baseline Demographic Characteristics of 97 Participating Providers
Age (Mean± SD)	35.4 ± 11.4
Age range, y	n (%)
<30	48 (49.5)
31 to 40	27 (27.8)
41 to 50	9 (9.3)
51 to 60	7 (7.3)
61 to 70	6 (6.2)
Gender
Male	47 (48.5)
Female	48 (49.5)
Prefer not to answer	2 (2.1)
Race
American Indian or Alaskan Native	0
Native Hawaiian or Other Pacific Islander	0
Asian	20 (20.6)
Black or African American	9 (9.3)
White	58 (59.8)
Multiracial	0
Other	4 (4.1)
Prefer not to answer	6 (6.2)
Ethnicity
Hispanic or Latinx	7 (7.2)
Not Hispanic or Latinx	86 (88.7)
Prefer not to answer	4 (4.1)

SD, standard deviation.

Table 2. Adult Attention Deficit Hyperactivity Disorder (ADHD) Toolkit Web Usage Data
Page Views of Section Webpages		Downloads of Toolkit Resources
Section	n (%)	Resource	n (%)
Toolkit Home Page	186 (47.2)	Adult ADHD Assessment and Diagnosis Approach Algorithm	30 (19.0)
Toolkit Home Page	186 (47.2)	ADHD Screeners & Quality of Life Assessments	23 (14.6)
Section 2: Adult ADHD Assessment & Diagnosis	72 (18.3)	Patient Handout: Managing Adult ADHD	14 (8.9)
		FDA Approved Stimulant Medications for Adult ADHD	11 (7.0)
		Physician Handout: Adult ADHD Treatment	11 (7.0)
Section 3: Treatment and Management of ADHD in Adults	52 (13.2)	Current Behavior Scale - Partner Report	11 (7.0)
		DSM-5 Diagnostic Criteria for ADHD	9 (5.7)
		Overview of Treatment Recommendations for Adult ADHD	9 (5.7)
Section 1: About Adult ADHD	40 (10.2)	Overview of Possible Causes for Presenting Symptoms Similar to ADHD	8 (5.1)
		Differential Diagnosis of ADHD in Adults	7 (4.4)
		Child Behavior Scale - Parent Report	6 (3.8)
Section 4: Risk Reduction	15 (3.8)	Symptoms of ADHD in Adults	4 (2.5)
Section 4: Risk Reduction	15 (3.8)	FDA Approved Non-Stimulant Medications for Adult ADHD	3 (1.9)
Section 5: Adult ADHD in Specific Patient Groups	15 (3.8)	National Resource Center on ADHD (CHADD): Diagnosis of ADHD in Adults*	3 (1.9)
Section 5: Adult ADHD in Specific Patient Groups	15 (3.8)	ADHD Risk Reduction Checklist	3 (1.9)
Section 6: FAQ	13 (3.3)	Adverse Effects of Selected Medications used in the Treatment of ADHD in Adults	3 (1.9)
Section 6: FAQ	13 (3.3)	Physician Handout: Adult ADHD Overview	1 (0.6)
Acknowledgments	1 (0.3)	Interventions for Minimizing Drug Misuse based on Patient Risk	1 (0.6)
Acknowledgments	1 (0.3)	Universal precautions to reduce stimulant misuse in treating adult ADHD*	1 (0.6)
Total	394	Total	158

*Non-AAFP, external document used with permission; Date Range: 11/1/2019 - 3/31/2020.
FDA, Food and Drug Administration; FAQ, Frequently Asked Questions.

Table 3. Logistic Regression Results of an Association of Residency Status, Number of Patients with Adult Attention Deficit Hyperactivity Disorder (ADHD), and Having Patients with ADHD on the Use of the AAFP Adult ADHD Toolkit.
	Exp(B)	Wald	P value
Residency status (resident vs non-resident)	0.56	1.06	.30
Number of adult patients with ADHD: 0 patients	1.08	0.006	.94
Number of adult patients with ADHD: 1 to 3 patients	0.49	0.59	.44
Number of adult patients with ADHD: 4 to 6 patients	5.54	1.35	.25
Saw patients with ADHD during the 17 weeks	49.53	21.87	<.001

Table 4. Impact of Toolkit on Knowledge and Confidence among Toolkit Users and Non-Users
Knowledge
	Users (Used Toolkit)		Non-Users (Did Not Used Toolkit)		F for Time	F for Time* Use
	n	Mean±SD	n	Mean±SD	F for Time	F for Time* Use
Nature of ADHD
Baseline	42	3.1±0.8	26	2.9±0.5	24.67*	0.20
Midpoint		3.1±0.8		3.0±0.8	24.67*	0.20
Final		3.6±0.7		3.5±0.7
Effects of ADHD on quality of life and risk associated with untreated ADHD
Baseline	43	3.2±0.9	25	3.0±0.8	16.52*	0.92
Midpoint		3.2±0.9		3.2±0.7	16.52*	0.92
Final		3.7±0.7		3.5±0.7
ADHD diagnostic process in adults
Baseline	43	2.7±0.8	24	2.6±0.7	24.00*	1.13
Midpoint		3.0±0.9		2.8±0.6	24.00*	1.13
Final		3.4±0.8		3.2±0.8
Management of ADHD in adults
Baseline	43	2.9±0.8	23	2.8±0.9	10.73*	1.65
Midpoint		3.3±0.8		2.9±0.6	10.73*	1.65
Final		3.5±0.8		3.2±0.8
Management of ADHD in young adults
Baseline	42	3.1±0.8	25	3.0±0.7	20.20*	1.32
Midpoint		3.4±0.7		3.0±0.8
Final		3.7±0.7		3.4±0.8
Management of ADHD in women
Baseline	43	3.0±0.8	25	2.9±0.6	15.02*	1.03
Midpoint		3.3±0.8		3.0±0.8	15.02*
Final		3.6±0.7		3.4±0.8
Management of ADHD in patients with co-morbid conditions
Baseline	42	2.7±0.7	26	2.8±0.7	7.98*	3.87*
Midpoint		3.2±0.7		2.7±0.6
Final		3.4±0.7		2.9±0.7
Management of ADHD in older adults
Baseline	43	2.5±0.6	26	2.4±0.8	24.60*	0.97
Midpoint		3.0±0.8		2.7±0.7
Final		3.2±0.6		3.0±0.7
Monitoring for treatment effects, side effects and outcomes
Baseline	41	3.1±0.8	26	3.1±0.7	8.15*	5.08*
Midpoint		3.6±0.8		3.0±0.7
Final		3.5±0.7		3.4±0.9
Patient safety with the use of stimulants in adults
Baseline	43	3.1±0.7	26	2.9±0.9	12.46*	0.15
Midpoint		3.3±0.8		3.0±0.7
Final		3.6±0.7		3.4±0.8
Prevention of non-medical use of stimulants in adults
Baseline	43	2.8±0.8	26	2.9±0.8	11.08*	2.49
Midpoint		3.1±0.7		2.8±0.9
Final		3.5±0.7		3.2±0.9
Understanding of potential for abuse of immediate-release stimulants
Baseline	42	3.1±0.8	24	3.2±0.8	9.44*	2.03
Midpoint		3.4±0.9		3.1±0.8
Final		3.8±0.9		3.4±0.9
Federal prescribing requirements for stimulants as controlled substance
Baseline	42	3.0±0.9	26	3.0±1.0	13.61*	1.54
Midpoint		3.5±0.9		3.2±0.9
Final		3.7±0.8		3.5±0.7
State prescribing requirements for stimulants as controlled substance
Baseline	42	3.1±1.0	26	3.0±1.1	15.17*	0.67
Midpoint		3.4±0.9		3.1±0.9
Final		3.6±0.8		3.6±0.6
Existing resources for patients and clinicians about adult ADHD
Baseline	42	2.5±0.8	26	2.6±0.8	28.09*	3.50*
Midpoint		3.3±0.9		2.9±0.7
Final		3.4±0.9		3.3±0.8
Communication with patients about any aspect of ADHD including the nature of ADHD, the medication treatment options, the non-pharmacological treatment options, patient's role in ADHD management, locating support services, training options and self-education resources, etc.
Baseline	43	3.0±0.8	25	2.7±2.5	20.41*	0.10
Midpoint		3.1±0.8		2.8±0.6
Final		3.6±0.8		3.3±0.8
Confidence
	Used Toolkit		Did Not Used Toolkit		F for Time	F for Time * Use
	n	Mean±SD	n	Mean±SD	F for Time	F for Time * Use
Diagnosing and treating ADHD in adults
Baseline	45	2.6±0.9	26	2.4±0.9	25.99*	1.33
Midpoint		3.3±0.8		2.8±1.0
Final		3.3±1.0		3.2±0.7
Recognizing and screening for ADHD in adults
Baseline	44	2.4±0.9	26	2.4±1.1	32.20*	1.76
Midpoint		3.2±0.9		2.8±0.9
Final		3.4±0.9		3.0±0.7
Making a diagnosis in patients who do not display classic childhood symptoms of hyperactivity and impulsivity
Baseline	45	2.0±1.0	26	1.8±1.0	20.49*	0.58
Midpoint		2.8±1.0		2.4±1.0
Final		3.0±1.0		2.5±1.0
Full evaluation of ADHD symptoms and coexisting disorders
Baseline	44	2.3±1.0	26	2.2±1.0	24.99*	2.07
Midpoint		3.0±1.0		2.5±0.9
Final		3.2±1.1		2.9±0.9
Use of rating scales as an initial screening step
Baseline	43	2.6±1.0	26	2.4±1.2	11.96*	0.14
Midpoint		3.1±0.9		2.7±1.3
Final		3.3±1.1		3.0±1.0
Mental health interview techniques and life history interview
Baseline	44	2.8±0.9	26	3.0±1.0	5.02*	4.22*
Midpoint		3.3±1.0		3.2±1.0
Final		3.5±0.9		3.0±0.8
Choosing treatment options for uncomplicated ADHD in adults
Baseline	44	2.8±1.0	26	2.7±1.2	22.21*	0.97
Midpoint		3.5±0.8		3.2±1.1
Final		3.6±1.0		3.2±0.8
Choosing treatment options for ADHD with co-morbid mental health disorders
Baseline	44	2.5±0.9	26	2.2±0.9	11.28*	5.39*
Midpoint		3.1±0.9		2.4±0.8
Final		3.2±1.0		2.3±0.8
Choosing treatment options for ADHD with co-existing substance use disorder
Baseline	45	2.0±1.0	26	1.9±1.0	17.21*	3.79*
Midpoint		2.8±1.1		2.1±0.9
Final		3.0±1.0		2.3±1.0
Follow up care practices
Baseline	45	2.8±1.0	26	2.7±1.0	18.78*	1.91
Midpoint		3.5±0.9		3.0±1.0
Final		3.5±0.9		3.0±0.9
Providing patient education related to any aspect of ADHD in adults
Baseline	45	2.6±1.0	26	2.4±1.0	28.61*	2.41
Midpoint		3.4±1.0		2.8±0.8
Final		3.6±0.9		3.0±0.9
Identifying and managing patients at risk for stimulant misuse, abuse and diversion
Baseline	45	2.6±1.0	26	2.5±0.9	10.94*	0.98
Midpoint		3.3±0.9		2.8±1.0
Final		3.2±1.0		2.9±1.0

ADHD, Attention Deficient Hyperactivity Disorder; SD, standard deviation.
*P value < 0.05.

Table 5. Needs Related to Adult Attention Deficit Hyperactivity Disorder (ADHD) Reported by Study Participants.
Needs	n (%)
Better understanding for non-medication management options, effectiveness and side effects	42 (51.9)
Better understanding diagnostic criteria and diagnostic process for adults	33 (40.7)
Differentiating adult ADHD from co-morbid disorders	32 (39.5)
How to appropriately screen for ADHD in adults	30 (37.0)
Understanding the presentation in an adult patient	30 (37.0)
Better understanding of treatment options for those with a history of substance abuse	30 (37.0)
Better understanding of medication management options and effectiveness	30 (37.0)
Prevention of stimulant abuse/misuse/diversion	29 (35.8)
More information about validated diagnostic and screening tools for adult ADHD	28 (34.6)
More patient education resources on management of adult ADHD symptoms besides taking medication	27 (33.3)
Tapering off medications	24 (29.6)
Understanding health risks of long-term stimulant use in adults	24 (29.6)
Understanding what resources are available in the local area for people who deal with ADHD	22 (27.2)