Clinical and cost-effectiveness of technologies for the assessment of attention deficit hyperactivity disorder: a systematic review and economic model.

Background: Attention deficit hyperactivity disorder is characterised by inattention, impulsivity and hyperactivity. Diagnosis is complex and time-consuming. Medication requires careful selection and dose titration. Technologies for objective measures of attention deficit hyperactivity disorder that use motion sensors to measure hyperactivity ('sensor continuous performance tests') may help improve the diagnostic process and medication management when used in addition to clinical assessment. Objective: To determine whether sensor continuous performance tests are clinically effective and cost-effective to the National Health Service. Specific objectives were to determine the effectiveness of sensor continuous performance tests for: diagnosis of attention deficit hyperactivity disorder in people referred with suspected attention deficit hyperactivity disorder diagnosis of attention deficit hyperactivity disorder in people referred with suspected attention deficit hyperactivity disorder for whom current assessment cannot reach a diagnosis during initial dose titration and treatment decisions for people with attention deficit hyperactivity disorder evaluating treatment effectiveness during long-term treatment monitoring for people with attention deficit hyperactivity disorder. Design: Systematic review and economic model (searches completed 17 November 2023). Results: Objective 1 [29 studies - 25 QbTest (QbTech Ltd., Stockholm, Sweden), 2 EF Sim (Peili Vision, Oulu, Finland) and 2 Nesplora Kids (Giunti Psychometrics, Florence, Italy)]: most evidence was in children. The AQUA trial was the only study to evaluate the QbTest in combination with clinical assessment and included a comparison with clinical assessment alone. Accuracy was similar and there was no statistical evidence of a difference between groups (p = 0.14), but the study was at high risk of bias. The AQUA trial reported that adding QbTest to the diagnostic process resulted in fewer appointments to reach a diagnosis, reduced consultation time, greater clinician confidence and exclusion of the diagnosis in a more children. Findings were supported by limited data from uncontrolled before-after studies. Qualitative and survey data reported increased clinician confidence in clinical decision-making, reduced time to diagnostic decision and improved communication. Barriers to implementation included staffing, training, technology requirements and length and repetitive content of the test. We found that using QbTest in addition to clinical assessment was likely cost-effective due to the reduced time waiting for assessment, reduced appointments until diagnosis and a higher proportion receiving treatment benefits. Objective 3 (six studies): All evaluated QbTest and most had concerns with risk of bias. Qualitative and survey data suggested that healthcare staff and families valued the QbTest for dose titration, checking medication utility and improving medication adherence. Some data suggested that results may not increase patient understanding and some clinicians highlighted logistical challenges. No studies were identified for objectives 2 and 4. Conclusions: Our results suggest that QbTesting as part of the diagnostic workup for attention deficit hyperactivity disorder in children (age < 18 years), when used in combination with clinical assessment, may be cost-effective. This finding was robust to nearly all assumptions made in the model. There are insufficient data on other sensor continuous performance tests in adults or on medication management. Future work: Diagnostic accuracy study evaluating comparing each of the sensor continuous performance tests plus clinical assessment. This should consider accuracy across different patient subgroups. Trial comparing patient outcomes and process measures in adults and children tested with and without sensor continuous performance tests with separate analyses for difficult-to-diagnose patients. Trial evaluating the role of sensor continuous performance tests in medication management, including long-term follow-up. Limitations: Lack of good-quality data on all tests, both for diagnosis and medication management, particularly when evaluated in combination with clinical information. Study registration: This study is registered as PROSPERO CRD42023482963. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR136009) and is published in full in Health Technology Assessment; Vol. 29, No. 58. See the NIHR Funding and Awards website for further award information.