ADHD is a treatable, common neurodevelopmental disorder affecting 5% of school-aged children, it is characterised by a persistent pattern of inattention and/or hyperactivity and impulsivity beyond the range of developmental norms. Untreated ADHD negatively affects personal, academic and familial functioning and can lead to further mental health problems i.e. depression, anxiety, eating disorders and self-harming.
Early intervention is severely hindered by an average 18-month delay to diagnosis from entry to ADHD services in the UK, the longest delay in Europe. The East Midlands Academic Health Science Network (EMAHSN) worked with Qbtech Ltd to address the need to improve patient experience, reduce time to diagnosis and achieve efficiency within ADHD care. EMAHSN deployed QbTest within seven Community Paediatric and CAMHS services.
The evaluation has shown that delays in diagnosis were reduced by an average of 145 days with 85% of patient respondents finding the QbTest helpful and that the results helped them to understand their symptoms. Cost savings were up to 39% with a release of 20-33% of clinicians time, with most patients requiring one fewer clinic visit for a diagnostic decision.
The primary challenge that we set to address was the delay from the first appointment to diagnosis, with the UK average being 18 months from 1st appointment to diagnosis. We aimed to achieve this by reducing the number of appointments required to rule in or rule out ADHD.
To make good use of the financial investment from the EMAHSN and resources from clinic staff and Qbtech we agreed on a goal for each clinic to test an average of 14 patients per month from January to December 2017. This set a target of 1170 patients to be tested and provided a benchmark to track implementation on a monthly basis.
Whilst improving efficiency we aimed to ensure that patient and family experience was positive and that clinicians found the innovation helpful in their understanding of patients symptoms and aided their communication with them. We measured these using patient and clinician satisfaction questionnaires developed by the University of Nottingham for the Assessing QbTest Utility in ADHD (AQUA) clinical trial.
A total of 1231 patients were assessed for ADHD using QbTest as part of the process during 2017, exceeding our target despite a slow start in most clinics due to the limited availability of trained staff. In each Trust an audit was undertaken of 20 – 30 cases before the project and 20-30 cases after the implementation of QbTest to gather baseline data and to measure the impacts.
The number of appointments required before the implementation of QbTest, to reach a diagnostic decision ranged from 3 to 8 across the three Trusts. Following the implementation, there was a reduction of one appointment per child, to reach a diagnosis. In two Trusts a diagnosis was reached at the first contact with the paediatrician, most of the time.
The average number of days to reach a decision before the implementation of QbTest ranged between 161 to 453 days. After the introduction of QbTest, this reduced to a range of 15 to 252 days. 85% of patient respondents found the QbTest helpful and that the results helped them to understand their symptoms and 94% of clinicians felt that they were better able to understand their patient’s symptoms of ADHD
Each of the Trusts has continued to fund their use of QbTest and have adjusted their staffing to enable continued use. The EMAHSN and Qbtech are now working on an adoption and spread project across England. This includes an example business case, case study video, social media campaign and an implementation toolkit.
The innovation has been put forward to the AHSN Atlas, an online resource that shares some of the best examples, from across the Academic Health Science Networks, to spread high impact innovation across the health and care system. Meetings to secure adoption and spread begin in June 2018, including Mental Health Commissioners and managers of ADHD services. This work will continue to the end of 2020.
Patients and families required on average one less visit to the clinic in for a diagnostic decision, reducing the time to diagnosis by 145 days. Time from assessment to treatment was reduced from between 161-453 days to 15-96 days, enabling earlier intervention in this debilitating yet treatable disorder. All three Trusts saw a return on investment (which ranged from approximately £14,000 to £93,900), a reduction in costs (range: 9% to 39% reduction) and a release in the clinical time required (range: 20% to 38% reduction).
Clinical time was released from paediatric/CAMHS clinic follow up outpatient appointments, and/or by replacing the need for a school visit by a qualified nurse. Observational school visits are costly and time consuming, unfortunately, it was not possible to attain an accurate figure for these costs and so the national tariff for a follow-up outpatient appointment was used. Therefore, the figures for time released and for cost savings are an underestimation.
Stakeholders included clinicians, managers and patients at each site. Clinicians were engaged through onsite training from clinical psychologists at Qbtech Ltd, visits and phone calls with the EMAHSN project manager and in the evaluation through staff surveys developed by the University of Nottingham.
Ninety patient and family experience questionnaires were distributed by clinic staff and 43% responded with 85% reporting that QbTest reports helped them to better understand their symptoms. Engagement of Trust managers was important throughout the implementation period to incorporate QbTest into their clinical pathways and essential in securing funding for the continuation of QbTest.
Early in the project the managers and clinicians at each site were highly motivated to retain the innovation to benefit their patients. Each site, together with senior management from the EMAHSN and Qbtech Ltd was represented at quarterly Steering Committee meetings where progress was evaluated, culminating in the finalisation of the evaluation report and commitment to working on adoption and spread across England.