Comparative effectiveness of ADHD treatments

I serve on the New England Comparative Effectiveness Public Advisory Council (CEPAC), the purpose of which is to translate medical science for patients, clinicians, and policymakers in the region. Our June meeting focused on ADHD.

Members of CEPAC recently convened in Durham, NH to deliberate and vote on the evidence on the clinical effectiveness and comparative value of treatment options for patients with attention deficit hyperactivity disorder (read the press release here).  This meeting examined the evidence on medication and behavior/psychosocial interventions for preschoolers and patients over the age of 6. The final meeting report includes supplementary analyses to augment the review of treatment options for ADHD produced by the Agency for Healthcare Research and Quality (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 ADHD treatment.  The report concludes with key policy implications from CEPAC to help guide patients, clinicians, insurers, and researchers to generate and apply evidence in ways that will improve the quality and value of psychiatric services across New England.

In preparing for and participating in this meeting, I learned a great deal about ADHD and treatments for it. More broadly, however, I learned just how challenging it is to apply comparative effectiveness research (CER). No studies make all the comparisons one would like to see, for the populations of interest, and with flawless methods. Consequently, one is forced to interpolate and extrapolate from what is available and in many dimensions simultaneously. In addition, whether something is worth the cost is a value call, but one we must (or should) make. For all these reasons, I found taking votes at the meeting to be an enormously difficult but incredibly important exercise.

Because of the inevitable imperfections of research, it’d be very easy for anyone to challenge the evidence CEPAC relied on or the conclusions it reached. And yet such challenges are insufficient to justify the status quo. Ultimately, we must make choices with uncertainty. I believe CER, even with its flaws, is the best tool we have. I’ve talked this talk for some time. Kudos for CEPAC and my fellow council members for walking the walk.


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