— Votes confirm the strength of evidence supporting parent behavior training in preschoolers and methylphenidate as first-line treatment for most school-age children receiving medication —
Boston, Mass., June 26, 2012 – Members of the New England Comparative Effectiveness Public Advisory Council (CEPAC) recently convened in Durham, NH to deliberate and vote on the evidence on treatment options for attention deficit hyperactivity disorder (ADHD). The meeting examined the evidence on treatments for preschoolers, as well as long-term outcomes for children over the age of 6. CEPAC is the central component of a project funded by the Agency for Healthcare Research and Quality (AHRQ), and directed by the Institute for Clinical and Economic Review (ICER), a leading academic comparative effectiveness research group based at the Massachusetts General Hospital’s Institute for Technology Assessment.
“In the backdrop of increasing rates of diagnosis of ADHD among U.S. children, these meeting results will help parents, clinicians, and insurers interpret and use the best available evidence on appropriate treatment,” stated Steven D. Pearson, MD, MSc, President of ICER. Using the AHRQ report as a foundation, CEPAC also reviewed important additional information on current treatment guidelines, medical policies and costs. The Council heard public comments and also deliberated on best practices with a roundtable of clinical experts, insurers, and patient representatives. Dr. Pearson continued, “Ultimately, CEPAC made judgments about the evidence and highlighted key action steps to support evidence-based clinical decisions and insurance policies that can improve outcomes for children with ADHD.”
Treatment for Preschoolers with ADHD: CEPAC was presented with data concerning the approaches to managing children under 6 with ADHD. CEPAC voted unanimously that parent behavior training, a psychosocial intervention aimed at helping parents manage disruptive behavior through positive rewards and other non-punitive tools, was better than usual care (wait-list control) for the preschool population; they also judged it to be of “reasonable value” compared to usual care. Similarly, a majority of CEPAC voted (10 to 3) that the evidence was adequate to demonstrate that methylphenidate (e.g., Ritalin®), was as good as or better than usual care (no specific ADHD management) for these children, with 9 saying it was better; most who voted that it was as good or better also judged it to be a “high value” compared to usual care. CEPAC cautioned that although the data on methylphenidate show its effectiveness, their positive votes do not imply that all preschoolers should receive medication as a first-line treatment for ADHD or that medication is an effective treatment option for all preschoolers.
Long-term Effectiveness for Children over Age 6: CEPAC stipulated unanimously that medications are better than usual care (community mental healthcare) in this age group. However, other votes from CEPAC concerning the evidence on long-term outcomes in children over 6 were less definitive. A slight majority of CEPAC voted (7 to 6) that evidence was adequate to demonstrate that other medications are as good as methylphenidate in treating ADHD, with CEPAC members emphasizing the superiority of some other medications in treating certain subpopulations (like children with anxiety disorders or tics) . However, when addressing the question of comparative value, a majority of CEPAC judged other medications to have “low value” compared to methylphenidate. While a majority of CEPAC voted (9 to 4) that the evidence was inadequate to demonstrate the benefit of parent behavior training over usual care (community mental healthcare) in this population, a majority did vote (10 to 2) that medication combined with psychosocial interventions (including parent behavior training) is better than medication alone. CEPAC members were split evenly on deciding whether combination therapy had low, reasonable or high value.
The final meeting report includes supplementary analyses to augment the review of treatment options for ADHD produced by AHRQ. The report also reviews the results of the votes taken by CEPAC on the adequacy of evidence to demonstrate the comparative clinical effectiveness and value of different approaches to treating ADHD. The report concludes with key policy considerations from CEPAC to help guide researchers, providers, and payers to generate and apply evidence in ways that will improve the quality and value of ADHD services across New England. ICER is also developing a Companion Policy Guide for clinicians, parents, patients and health plans to aid in the implementation of the CEPAC votes. That policy guide will be available in July.
CEPAC is a regional body whose goal is to provide objective, independent guidance on the application of medical evidence to clinical practice and payer policy decisions across New England. Supported by a federal grant from the Agency for Healthcare Research and Quality (AHRQ), and with backing from a consortium of New England state health policy leaders, CEPAC holds public meetings to consider evidence reviews of medical tests and treatments and provide judgments regarding how the evidence can best be used across New England to improve the quality and value of health care services. CEPAC consists of practicing physicians with experience in evaluating and using evidence in the practice of healthcare, as well as patient/public members with experience in health policy, patient advocacy and public health. ICER is managing the day-to-day operations of CEPAC as part of its federally funded RAPiD (Regional Adaptation for Payer Policy Decisions) initiative meant to develop and test new ways to adapt federal evidence reviews to improve their usefulness for patients, clinicians, and payers. A list of CEPAC members, and other information about the project, is available online at cepac.icer-review.org.
The Institute for Clinical and Economic Review (ICER), based at the Massachusetts General Hospital’s Institute for Technology Assessment (ITA) and an affiliate of Harvard Medical School, provides independent evaluation of the clinical effectiveness and comparative value of new and emerging technologies. Structured as a fully transparent organization, ICER seeks to achieve its ultimate mission of informing public policy and spurring innovation in the use of evidence to improve the value of health care for all. For more information, please visit www.icer.org