QbTest for ADHD assessment and medication management: a mixed-methods systematic review of impact on clinical outcomes and patient, carer and clinician experiences

Objectives
To explore patient, carer and clinician experiences of the QbTest and its impact on patient outcomes for attention deficit hyperactivity disorder (ADHD) diagnosis and medication management.

Design
Mixed-methods systematic review.

Data sources
MEDLINE, EMBASE, PsycINFO, CINAHL, ClinicalTrials.gov and WHO ICTRP (from inception to September 2024).

Study selection
Primary studies, of any design, that evaluated any version of the QbTest (QbMini <5 years, QbTest 6–12 or 12–60 years, QbCheck for remote assessment via webcam or QbMT smartphone version), for ADHD diagnosis and/or medication management and provided data on any of the following outcomes, were eligible: time to assessment/diagnostic decision, use of services, impact on clinical decision-making, healthcare professionals’ confidence in assessment, intervention use, morbidity, mortality, health-related quality of life, cost, ease of use, experience and acceptability of the test to patients, carers and clinicians.

Data extraction and synthesis
Two reviewers independently screened titles and abstracts and assessed potentially relevant reports for inclusion. One reviewer conducted data extraction and risk of bias (RoB) assessment, checked by a second reviewer. Mixed-methods synthesis followed the convergent-integrated approach.

Results
We identified 10 eligible studies (9 QbTest; 1 QbCheck), including 1 randomised controlled trial (RCT), 2 feasibility RCTs, 5 before-and-after studies, 1 mixed-methods study and 1 diagnostic study. Most studies enrolled children in the UK and included surveys or interviews with patients, carers or clinicians. The RCT and before-and-after studies were judged at high/serious RoB. Six survey components and two qualitative interview components were judged at some concerns of RoB. We identified one ongoing study of the QbMT and no studies for QbMini. We organised themes emerging from the qualitative synthesis into two broad conceptual categories: views around the helpfulness of the QbTest (contribution to ADHD diagnosis, treatment decision-making, communication with caregivers) and barriers to QbTest implementation (practical barriers and acceptability of the test to patients and caregivers). Findings suggested that the addition of the QbTest may reduce time to diagnosis, improve clinician confidence in the diagnostic decision, increase the proportion of patients with a diagnostic decision and reduce cost and number of clinic appointments. The QbTest appeared to be generally well received by clinicians, patients and carers. However, barriers to test implementation were reported. Clinicians cited staffing, room requirements and issues with technology, and patients highlighted the test length and repetitive nature. Little data exist on the use of the QbTest for medication management.

Conclusions
The available evidence suggests the QbTest may be a useful addition to ADHD assessment in children and young people. Further well-designed RCTs with qualitative substudies are required to assess the impact of the QbTest on patient outcomes, user experience and cost, particularly for medication management and in adults, where evidence is scarce. Such RCTs should include economic analyses, direct comparisons to other continuous performance tests with motion trackers and subgroup analyses including age, sex, ethnicity and comorbidities.

PROSPERO registration number
CRD42023482963.