Winner of the 2018 HSJ Award for Innovation in Mental Health, this innovative programme is being rolled out from April 2020 across the AHSN Network. Pioneered in the East Midlands it supports more effective diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), primarily for young people but also for adults
The innovation has been mainstreamed within three NHS trusts in the East Midlands – by early 2020 it has spread to 80 NHS sites and via the AHSN Network will be spread even further.
The East Midlands demonstrator was based on QbTest is a diagnostic tool based on a digital continuous performance test (CPT). It is the only CE marked, European Medicines Agency (EMA) registered and Food and Drug Administration (FDA) cleared intervention that simultaneously measures attention, impulsivity and motor activity. These are core indicator symptoms of ADHD and accurate measurement supports a timely clinical diagnosis.
The AHSN worked with international medical technology company Qbtech Ltd to roll out QbTest at seven sites in three NHS Trusts and provided funding for first year implementation. The project tested out two different models and evaluation of the 12 month demonstrator (2017 to 2018) shows impressive results:
- Time from assessment to diagnosis reduced by an average of between 146 and 201 days
- Net cost reductions of up to 39% overall (one model saw net cost reductions of 32.6% and 39.2%; where the other model was 9.85%)
- released between 20 and 33% in clinical workforce time
- 85% of patients surveyed reported their results helped them to understand their symptoms.
Based on these results the intervention is mainstreamed, with the three trusts committed to funding beyond 2018 (United Lincolnshire Hospitals NHS Trust, Derbyshire Healthcare NHS Foundation Trust and Leicestershire Partnership NHS Trust).
“The support of the East Midlands AHSN and the skilled clinicians who have been fundamental to this project have allowed us to demonstrate the impact and value of QbTest, both for patients and the NHS. We are delighted that our technology will continue to be used across these sites. We believe that the independent evaluation from the East Midlands AHSN showing cost savings and reduced waits for diagnosis will compel many other Trusts and CCGs to adopt QbTest to benefit their patients.”
Tony Doyle, Managing Director, Qbtech
ADHD is a treatable, common neurodevelopmental disorder affecting 5% of school-aged children worldwide1. It is characterised by a persistent pattern of inattention and/or hyperactivity and impulsivity beyond.
The annual cost to the UK in NHS, social care and education resources is estimated to be £670 million2 and around 12,000 young people are thought to have the condition in the East Midlands.
Undiagnosed and/or untreated ADHD can have significant negative effects on the person’s personal, academic and family interactions and can lead to additional mental health problems including depression, anxiety, eating disorders and self-harming.
Current diagnosis techniques are highly subjective based on clinical interpretation, service user and parent feedback, and this can delay effective diagnosis and time to treatment: British children wait on average 18 months from their first GP appointment to receiving a formal ADHD diagnosis, comparing negatively with the European average wait of 11-months.3
- Faraone, Sergeant, Gilberg & Biederman (2003)
- Telford, C., Green, C., Logan, S., Langley, K., Thapar, A., & Ford, T. Estimating the costs of ongoing care for adolescents with attention-deficit hyperactivity disorder (2013).
- Fridman M, Banaschewski T, Sikirica V, Quintero J, Chen KS. Access to diagnosis, treatment and supportive services among pharmacotherapy treated children and adolescents with ADHD in Europe (2017)
“We know it’s important for families to get advice and support as quickly as possible when a child is thought to have ADHD. Having a computerised tool like QbTest is contributing to effective medications management and helping to reduce the time to diagnosis, which in turn alleviates families’ uncertainty.”
Donna Whitemore, Team Manager of the Neurodevelopmental Service, Derbyshire Healthcare NHS Foundation Trust
The East Midlands demonstrator (up to March 2020) supported spread to 82 NHS sites nationally including seven sites (within three NHS Trusts) in the East Midlands.
The AHSN’s involvement has been key to evaluating the innovation:
- funding and evaluating the demonstrator project
- testing out and evaluating different approaches to using the technology
- developing a robust business case to support rapid adoption and spread
- understanding the NHS market to support highly targeted engagement with Trusts
- developing a coordinated approach to adoption and spread within and beyond the East Midlands (from 2018)
- The East Midlands demonstrator focused on deploying the QbTest diagnostic tool within Community Paediatric Mental Health services in Derbyshire, Leicestershire, Lincolnshire and CAMHS (Child and Adult Mental Health Services) in Derbyshire, funded by the AHSN for year one from January 2017.
QbTest monitors an individual’s ‘push button’ responses to a target appearing on a computer screen. Whilst simultaneously tracking their head movement using an infra-red camera. Output data is captured in a visual report which is available immediately following test completion and compares the result against an age and gender matched normative control group.
Each of the three trust areas deployed the QbTest differently, in response to the needs of their service and available resources. In all cases it was used to support the diagnostic process for children referred for assessment of possible ADHD.
Two trusts redesigned their discrete ADHD assessment pathways, placing QbTest at the beginning of the patient journey. The remaining Trust implemented it into an existing neurodevelopmental patient pathway, using QbTest to support the assessment of ADHD in complex cases.
“I was reassured that all of the results and assessments confirmed ADHD. It was nice to see this QbTest and I kept a copy to show my family to help them understand too.”
The project is to deliver three key benefits:
- Improving patient experience
- Reducing time to diagnosis
- Achieving greater efficiency within ADHD care.
A highly structured approach was taken to evaluating the intervention, comprising:
- Each trust auditing 20-30 cases both before and after the implementation of QbTest to gather baseline data and measure impacts. To ensure best use of the EMAHSN investment and clinic staff resource and provide month-on-month implementation benchmarking, the partners agreed a target of 1,170 patients to be tested in the 12 months to December 2017.
- Site-specific evaluations were completed as well as an overall evaluation across all seven sites. Qualitative data was collected through patient and clinician satisfaction questionnaires developed by the University of Nottingham and the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) East Midlands as part of the Assessing QbTest Utility in ADHD (AQUA) clinical trial (clahrc-em.nihr.ac.uk/research/aqua-trial)
- In the AQUA trial in mental health and community paediatric clinics in England, 267 participants aged 6-17 years-old and their clinicians were randomised to either receive the QbTest report or not as part of their standard diagnostic assessment for ADHD. In the study, 132 of the 267 participants and their clinicians received the QbTest report.
The AQUA clinical trial was the first independent randomised-controlled study ever undertaken that has demonstrated that an objective assessment technology – QbTest – can increase the speed and efficiency of diagnostic decision-making in ADHD.
The study results suggest that QbTest is ready for adoption and spread within the ADHD assessment pathway in the UK, and in other countries with similarly long delays to diagnosis, where it is likely to lead to earlier diagnostic decisions and significant healthcare system efficiencies.
Clinicians with access to the QbTest report were more likely to reach a diagnostic decision about ADHD. At six months, 76 per cent of those with a QbTest report had received a diagnostic decision, compared with 50 per cent without. The QbTest reduced appointment length by 15 per cent, increased clinicians’ confidence in their diagnostic decisions, and doubled the likelihood of excluding ADHD. There was no difference in diagnostic accuracy.
The use of QbTest in the three East Midlands trust areas (covering Community Paediatric services and CAMHS) saw cost savings and a return on investment. It reduced the number of appointments and the time taken to reach a diagnostic decision – suggesting enhanced service efficiency, improved quality of care and increased patient satisfaction.
Evaluation findings indicate potential in reduced workload for the ADHD nurses, given the time saving released from undertaking observational school visits and compiling the subsequent reports.
Specific outcomes and impacts include:
- The costs of QbTest per trust is £535 per month, with a cost of £18 per test. All three trusts involved in the demonstrator saw a return on investment of between £14,300 and £93,900 and reduction in costs from 9% to 39%, providing an estimated net NHS saving of between £14,000 and £93,900 in year one (the differences between the trusts relates to different pathway changes implemented and variation in tariff costs).
- Staff surveys show clinicians felt the QbTest supported both diagnostic decision-making and in communicating decisions to patients and families – 94% said they were better able to understand their patients’ symptoms of ADHD.
- 1,231 patients were assessed using QbTest during 2017, exceeding the target and ensuring best use of resources during implementation and effective capture of robust benchmarking data.
- Reduction in clinical time required to rule in or rule out ADHD in children over a one year period ranged from a 20% to 33% (Based on time released per child, multiplied by the number of children seen in the one year period of the study).
- Average number of days to reach a decision before the implementation of QbTest ranged between 161 to 453 days. With QbTest this reduced to a range of 15 to 252 days.
- Number of appointments required to reach a diagnostic decision before the implementation of QbTest ranged from three to eight across the trusts. Following the implementation, there was a reduction of one consultant appointment per child to reach a diagnosis and release of an average between 0.24 and 1.04 total number of appointments on the pathway. In two trusts diagnosis was reached at the first contact with the paediatrician in the majority of cases.
- 90 patient and family experience questionnaires were distributed by clinic staff and 43% responded with 85% of these reporting that QbTest reports had helped them to better understand their symptoms.
- Sustainability has been achieved, with all three demonstrator trusts mainstreaming funding for QbTest from 2018 based on positive outcomes and evaluation. All have signed contracts with Qbtech for the ongoing provision of QbTest.
- EMAHSN and Qbtech Ltd were named as winners of the 2018 HSJ Award for Innovation in Mental Health for a mental health innovation that is leading the way in delivering better services and evidence of financial savings alongside improved patient experience.
“The QbTest provides an up-to-date platform to test and observe young people and gain meaningful data, which can be easily interpreted to support the diagnostic process. It helps to reduce clinical observation time, supporting an overall reduction in time for the diagnostic process. The QbTest also supports ongoing monitoring and efficacy of the use of medications, which is a huge help.”
Fran Guerra, Neurodevelopmental Nurse Specialist, Leicestershire Partnership NHS Trust
Sustainability has been achieved with all three demonstrator trusts mainstreaming funding from 2018 based on positive outcomes and evaluation.
Based on the outstanding impacts from the East Midlands demonstrator, this project has been developed into a new programme called ‘Focus ADHD’, which is being rolled out nationally across AHSNs in a phased approach from April 2020.
East Midlands demonstrator started in January 2017 (ongoing) and adoption as a AHSN network spread programme commenced from April 2020.
The 12-month demonstrator ran from January 2017 to December 2017. Ongoing collaboration between EMAHSN and Qbtech Ltd to facilitate adoption and spread will from April 2020 – to date
Dara Coppel, Head of Innovation Programme Delivery, East Midlands AHSN
Tony Doyle, Managing Director, Qbtech Ltd
T: +44 (0)208 996 5148
M: +44 (0)7771 937 845
Chris Taylor, Associate Director of Communications & Engagement, East Midlands AHSN