Appendix C. Detail on criteria for audit of the use of methylphenidate, atomoxetine and dexamfetamine for attention deficit hyperactivity disorder (ADHD) in children and adolescents

Appendix C. Detail on criteria for audit of the use of methylphenidate, atomoxetine and dexamfetamine for attention deficit hyperactivity disorder (ADHD) in children and adolescents

Possible objectives for an audit

An audit could be carried out to ensure that methylphenidate, atomoxetine and dexamfetamine are prescribed appropriately for children and adolescents who have ADHD.

Possible patients to be included in the audit

An audit could be carried out on all children and adolescents who are referred with symptoms of ADHD in a reasonable time period for audit, for example, 6 months to 1 year, and for whom it is considered that drug treatment is appropriate.

Alternatively, the audit could include all children and adolescents who are referred with symptoms of ADHD and drug treatment not considered to be appropriate could be specified as an exception in those audit measures that refer to drug treatment.

Measures that could be used as a basis for an audit

The measures that could be used in an audit of methylphenidate, atomoxetine and dexamfetamine for ADHD are as follows.

Criterion

Standard

Exception

Definition of terms

1. Drug treatment for a child or adolescent with ADHD is:

a. initiated only by an appropriately qualified healthcare professional with expertise in ADHD and

b. based on a comprehensive assessment and diagnosis.

100% of children and adolescents in the audit for whom drug treatment is prescribed for 1a and b.

None

Clinicians will need to agree locally on the data source for determination of who initiated the drug treatment.

Clinicians will need to agree locally on defining an appropriately qualified healthcare professional with expertise in ADHD, for audit purposes, for example, a child and adolescent psychiatrist or a paediatrician or learning disability expert with specialised training and experience in ADHD.

Clinicians will need to agree locally on what constitutes a comprehensive assessment and diagnosis, for audit purposes.

2. For those children for whom drug treatment is determined to be appropriate, methylphenidate, atomoxetine or dexamfetamine is offered, within licensed indications, as an option.

100% of children and adolescents in the audit for whom drug treatment is determined to be appropriate.

None

Methylphenidate is available as Ritalin, Equasym, Concerta XL or Equasym XL. Atomoxetine is available as Strattera. Dexamfetamine is available as Dexedrine.

Methylphenidate and atomoxetine are not currently licensed for use in children less than 6 years of age. Dexamfetamine is not currently licensed for use in children less than 3 years of age.

Clinicians will need to agree locally on how it is determined that drug treatment is appropriate and how the offering of the option of drug therapy is documented, for audit purposes.

3. The decision regarding which product to use considers the following:

a. the presence of comorbid conditions and

b. the different adverse effects of the drugs and

c. specific issues regarding compliance identified for the individual child or adolescent and

d. the potential for drug diversion and/or misuse and

e. the preferences of the child or adolescent and/or his or her parent or guardian.

100% of children and adolescents in the audit who are prescribed methylphenidate or atomoxetine or dexamfetamine.

None

'Comorbid conditions' include tic disorders, Tourette's syndrome or epilepsy.

See the Summary of Product Characteristics for adverse effects of the drugs.

'Specific issues regarding compliance' could include problems created by the need to administer a mid-day dose at school.

'Drug diversion' could include where the medication is forwarded to others for non-prescription uses.

Clinicians will need to agree locally on how consideration of 3 (a)–(e) is documented, for audit purposes.

4. If there is a choice of more than one appropriate drug, the drug with the lowest cost is prescribed.

100% of children and adolescents who are prescribed drug treatment.

None

'Cost' takes into account daily required dose and product price per dose. Clinicians will need to agree locally on the source of cost information, for audit purposes.

Calculation of compliance

Compliance (%) with each measure described in the table above is calculated as follows.

Number of patients whose care is consistent with the criterion plus number of patients who meet any exception listed

x 100

Number of patients to whom the measure applies

Clinicians should review the findings of measurement, identify whether practice can be improved, agree on a plan to achieve any desired improvement and repeat the measurement of actual practice to confirm that the desired improvement is being achieved.