David M Foreman1, Stephanie Morton. 1. The Isle of Man, Government and Royal Holloway, University of London, UK. david_foreman@doctors.net.uk
Abstract
BACKGROUND: Nurse prescribers may be a cost-effective alternative to doctors in managing attention deficit hyperactivity disorder, but to date there has been no study of their relative effectiveness, and there are concerns about their usage. We therefore undertook a direct comparison of nurse-delivered and doctor-delivered attention deficit hyperactivity disorder care in an attention deficit hyperactivity disorder follow-up clinic. METHOD: Seventy patients were identified between February 2005 and September 2006, 36 managed by an attention deficit hyperactivity disorder specialist nurse, 34 by doctors. Average age at referral was 7·1 years; their duration in the service was 5·5 years. Outcomes included changes since admission in the predicted diagnostic category from Strengths and Difficulties Questionnaire scores, the Commission for Health Improvement patient satisfaction questionnaire and a clinic-developed side-effect questionnaire. Propensity score matching and multiple imputation were used to manage selection bias and missing data. The impact of nurse management was estimated using the Average Treatment effect on the Treated statistic with 95% confidence intervals. RESULTS: All the Average Treatment effects on the Treated approximated zero. Inspecting the confidence intervals suggested that there was, at worst, 2·5% risk of nurses underidentifying emotional disorders with respect to doctors. CONCLUSIONS: There seems little to distinguish the quality of doctor- or nurse-delivered care in ordinary attention deficit hyperactivity disorder follow-up clinics. There seems no clinical impediment to using nurse prescribers to increase clinic capacity. It may be useful to add structured assessment of mood difficulties at follow-up if nurse prescribers are used.
BACKGROUND: Nurse prescribers may be a cost-effective alternative to doctors in managing attention deficit hyperactivity disorder, but to date there has been no study of their relative effectiveness, and there are concerns about their usage. We therefore undertook a direct comparison of nurse-delivered and doctor-delivered attention deficit hyperactivity disorder care in an attention deficit hyperactivity disorder follow-up clinic. METHOD: Seventy patients were identified between February 2005 and September 2006, 36 managed by an attention deficit hyperactivity disorder specialist nurse, 34 by doctors. Average age at referral was 7·1 years; their duration in the service was 5·5 years. Outcomes included changes since admission in the predicted diagnostic category from Strengths and Difficulties Questionnaire scores, the Commission for Health Improvement patient satisfaction questionnaire and a clinic-developed side-effect questionnaire. Propensity score matching and multiple imputation were used to manage selection bias and missing data. The impact of nurse management was estimated using the Average Treatment effect on the Treated statistic with 95% confidence intervals. RESULTS: All the Average Treatment effects on the Treated approximated zero. Inspecting the confidence intervals suggested that there was, at worst, 2·5% risk of nurses underidentifying emotional disorders with respect to doctors. CONCLUSIONS: There seems little to distinguish the quality of doctor- or nurse-delivered care in ordinary attention deficit hyperactivity disorder follow-up clinics. There seems no clinical impediment to using nurse prescribers to increase clinic capacity. It may be useful to add structured assessment of mood difficulties at follow-up if nurse prescribers are used.