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The Attention-Deficit Hyperactivity Disorder Paradox: 2. Phenotypic Variability in Prevalence and Cost of Comorbidity

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The Attention-Deficit Hyperactivity Disorder Paradox: 2. Phenotypic Variability in Prevalence and Cost of Comorbidity. Larry Burd, PhD; Marilyn G. Klug, PhD; Matthew J. Coumbe, PhD; Jacob Kerbeshian, MD. Abstract.

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slide1

The Attention-Deficit Hyperactivity Disorder Paradox: 2. Phenotypic Variability in Prevalence and Cost of Comorbidity

Larry Burd, PhD; Marilyn G. Klug, PhD; Matthew J. Coumbe, PhD; Jacob Kerbeshian, MD

abstract
Abstract
  • The objective of this study was to use population-based data to estimate the cost and phenotypic variation of conditions comorbid with attention-deficit hyperactivity disorder (ADHD). The case population was 7745 children. We then examined the 10 most frequent comorbidities for a defined condition from the ICD-9. The observed prevalence of general health conditions was 12 to 70% less than expected. The presence of a comorbid condition resulted in increases in costs of care of $381 to $731 per case per year. The observed prevalence of comorbid mental health conditions was 97 to 5286% higher than expected. We identified an ADHD paradox: decreased rates of comorbid general health conditions and increased rates of comorbid mental disorders. Further research on comorbidity in ADHD is required. (J Child Neurol 2003;18:653-660).
study population
Study Population
  • The original data set consisted of 1,509,980 visits made by children ages 0 to 21 years in North Dakota in 1996 and 1997. This included both inpatient and outpatient visits. For the 2 years combined, a total of 1,473,611 visits were included in this analysis. This represented (averaged over 1996 and 1997) visits made by 197,983 uniquely identified children (88,702 in 1996 and 109,281 in 1997).
inclusion criteria cases
Inclusion Criteria: Cases
  • Patients were included in the study as cases with ADHD if at any time during either year they had an International Classification of Diseases, 9th edition (ICD-9), code of 314.00 or (attention-deficit disorder not otherwise specified), 314.00 or (inattentive type), 314.01 (with hyperactivity/impulsiveness), or 314.8 (with other specific manifestations). The code 314.9 (attention-deficit hyperactivity disorder not otherwise specified) was also included to capture cases from the Diagnostic and Statistical Manual of Mental Diseases-IV (DSM-IV).
inclusion criteria controls
Inclusion Criteria: Controls
  • The control population consisted of all remaining subjects in the database who did not have an ICD-9 code of 314.00, 314.01, or 314.8 or the DSM-IV code of 314.9 in their diagnostic formulation at any time during the 2-year span of the study. There were 24.5 controls per case in this study.
limitations
Limitations
  • The validity of the diagnosis reported needs to be considered.
    • These data are from a single rural state, and the subjects are not currently traceable across years or type of claims.
    • The data set does not include uninsured children or children who did not access health care in the 2-year period included in this study.
prevalence of adhd by age group gender and payer type
Prevalence of ADHD by Age Group, Gender, and Payer Type

ADHD = attention-deficit hyperactivity disorder

results
Results
  • Prevalence and Base Costs of ADHD
    • The prevalence of ADHD in these claims data was 3.9% or 7,745 children (4,317 in 1996 and 3,428 in 1997).
slide9
Prevalence and Risk of 4 Most Common General and Neurologic Diagnoses in Children With ADHD Compared With Children Without ADHD (Controls)

Respiratory illness: 465.xx; Acute pharyngitis: 462.xx

ADHD = attention-deficit hyperactivity disorder; AR% = attributable risk percentage

slide10
Prevalence and Risk of 4 Most Common General and Neurologic Diagnoses in Children With ADHD Compared With Children Without ADHD (Controls)

Vision: 367.xx; Suppurative otitis media: 382.xx

ADHD = attention-deficit hyperactivity disorder; AR% = attributable risk percentage

comorbidity with general and neurologic diagnosis
Comorbidity With General and Neurologic Diagnosis
  • Prevalence
    • These data identify an important association between a diagnosis of ADHD and a decrease in the total risk of these comorbid conditions. This suggests the possibility of a protective effect from ADHD for several common illnesses.
slide12
Comparison of Mean Costs of Common General and Neurologic Illnesses Between Children With ADHD and Controls (Base Cost=$495, Cost Attributable to ADHD=$154)

ADHD = attention-deficit hyperactivity disorder

slide13
Comparison of Mean Costs of Common General and Neurologic Illnesses Between Children With ADHD and Controls (Base Cost=$495, Cost Attributable to ADHD=$154)

ADHD = attention-deficit hyperactivity disorder

costs
Costs
  • The cost of care for these comorbid general health conditions was increased.
  • The equation for the total annual cost of care ($1133) is composed of:
    • Base cost of care for a control child ($495)
    • Cost of care attributable to ADHD ($154)
    • Cost of care attributable to respiratory illness in controls without ADHD ($164)
    • The cost of comorbidity ($1133-$495-$154-$164=$320).
slide15
Comparison of Mean Costs of Common Mental Illnesses Between Children With ADHD and Controls (Base Cost=$495, Cost Attributable to ADHD=$154)

ADHD = attention-deficit hyperactivity disorder

slide16
Comparison of Mean Costs of Common Mental Illnesses Between Children With ADHD and Controls (Base Cost=$495, Cost Attributable to ADHD=$154)

ADHD = attention-deficit hyperactivity disorder

slide17
Prevalence and Risk of 4 Most Common Mental Diagnoses in Children With ADHD Compared With Children Without ADHD

Depression: 293.83, 296.2x, 296.3x, 296.5x, 296.82, 298.0x, 300.4x, 301.12, 309.0x, 309.1x, 309.28, 311.xx, and 313.1x; Oppositional defiant disorder: 3131.81

ADHD = attention-deficit hyperactivity disorder; AR%= attributable risk percentage

slide18
Prevalence and Risk of 4 Most Common Mental Diagnoses in Children With ADHD Compared With Children Without ADHD

Bipolar: 296.xx; Conduct disorders: 312.xx

ADHD = attention-deficit hyperactivity disorder; AR% = attributable risk percentage

prevalence comorbidity with mental and neurologic disorders
Prevalence: Comorbidity With Mental and Neurologic Disorders
  • The relative risks of a child with ADHD being diagnosed with an additional mental disease were all greater than 1, ranging from 3.2 (nondependent drug use) to 53.4 (oppositional defiant disorder).
  • Children with ADHD were 53 times more likely to have oppositional defiant disorder than controls.
four disorders
Four Disorders
  • Oppositional defiant disorder, conduct disorders, learning disabilities, and tics
    • Have an attributable risk percentage above 90%
    • This suggests that ADHD represents an important risk marker for multiple mental health disorders.
policy implications costs
Policy Implications: Costs
  • Attributable costs for mental disorders ranged from $204 (tic disorder) to $1262 (personality disorder).
  • The cost of care attributable to depression in a control child was $566 ($1061-$495).
  • The cost of comorbidity in children with ADHD and depression was $115 ($1330-$495-$154-$566=$115).
clinical implications
Clinical Implications
  • We have identified an ADHD comorbidity paradox
  • This was a decrease of 12 to 70% of the expected number of cases.
  • In contrast, there were 26 to 698 additional cases of vision problems, epilepsy, depression, oppositional defiant disorder, bipolar disorder, conduct disorder, adjustment disorder, anxiety disorder, nondependent drug use, tic disorders, personality disorders, epilepsy, and visual impairment.
  • For these illnesses, the number of observed cases was increased by 97 to 5286% over the expected number
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