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

The study included only 105 of 166 invited clinicians from 19 practices in one hospital-owned network, and practices that did not participate cited competing priorities or other research, so results may not apply to other settings. Children with autism spectrum disorder were excluded, so results may not apply to that group. Only 4 charts per clinician per period were reviewed, for 790 charts total, which limited power to detect modest differences. Participants and study staff were not blinded to group assignment. Both intervention and control clinicians had access to the ADHD Care Assistant electronic system, and its rollout may have improved both groups, so the contribution of the quality improvement program alone cannot be separated. The SHARE program combined education, expert consultation, and performance feedback, so the contribution of any single component cannot be separated. Engagement in the intervention was modest: 30 of 53 intervention clinicians joined at least one feedback call, and 19 completed all parts and maintenance of certification attestation. The primary outcome was rating scale administration and return, not ADHD symptoms or functional outcomes, and symptom scores were not routinely recorded. The chart review did not distinguish initial ADHD rating scales from follow-up scales. The study did not record whether clinicians were prescribing medication for each child. All three urban practices had embedded mental health professionals, and their possible influence was not separated. Practice-level results varied widely, from 6.3% to 50.0% change in intervention practices and -5.0% to 50.0% in control practices.

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Do not conclude that distance-learning quality improvement alone improves ADHD care. The randomized between-group comparison was not significant, and both groups improved during the period when the electronic Care Assistant became available. The higher parent rating scale use among more engaged clinicians was a secondary analysis within the intervention arm, not proof that the intervention worked.