{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T16:49:33Z","timestamp":1785775773995,"version":"3.56.0"},"reference-count":40,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T00:00:00Z","timestamp":1785715200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Psychiatry"],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>National evidence indicates that attention-deficit hyperactivity disorder (ADHD) referrals, recorded diagnoses and waiting lists have increased substantially. The Comprehensive ADHD Screening Questionnaire (CASQ), a criterion-based tool delivered by trained Band 7 clinicians, achieved 100% sensitivity, with a 95% confidence interval of 61.0\u2013100.0%, while screening out 39.6% of referrals in a prospective NHS validation study of 48 participants. This analysis compares the costs and diagnostic consequences of the CASQ-first pathway with full ADHD assessment from the NHS perspective.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A prospective observational study-based cost-consequence analysis was conducted from the NHS perspective over a one-year time horizon, following the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022.\u00a0A non-inferiority margin of \u221210 percentage points, corresponding to sensitivity of at least 90%, was specified to assess diagnostic safety. The CASQ assessment-and-triage cost was \u00a3120.27 per referral, derived bottom-up from Personal Social Services Research Unit (PSSRU) 2024 unit costs. The standard or low-complexity full ADHD assessment cost was \u00a3850, taken from the final NHS England 2026\/27 Adult ADHD Assessment, Face-to-Face guide price. The weighted-mean full ADHD assessment cost was calculated using South West Yorkshire Partnership Teaching NHS Foundation Trust (SWYPFT) case-mix proportions from a previous explainable clustering analysis, giving \u00a31, 011.28 per referral. Sensitivity analyses examined alternative cost assumptions, proportion screened out, CASQ duration and incremental clinical time for more complex full ADHD assessment cases. An expanded structural probabilistic sensitivity analysis with 10, 000 Monte Carlo simulations separately propagated uncertainty in complexity-cluster proportions, incremental Band 7 clinical hours, CASQ assessment-and-triage cost, standard full ADHD assessment cost, Band 7 hourly cost and diagnostic accuracy parameters.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The CASQ achieved 100% sensitivity and 100% negative predictive value in the validation study. In the SWYPFT case-mix weighted-mean base case, the CASQ-first pathway cost \u00a3731.08 per referral compared with \u00a31, 011.28 for universal full ADHD assessment, a saving of \u00a3280.20 per referral and \u00a3598, 507 annually at 2, 136 referrals. In commissioning terms, this corresponds to an estimated saving of approximately \u00a3280, 200 for every 1, 000 referrals managed through the CASQ-first pathway under the SWYPFT case-mix weighted base case. In the expanded structural probabilistic sensitivity analysis, the CASQ-first pathway was cost-saving in 100.0% of 10, 000 simulations, with a mean saving of \u00a3285.18 per referral and \u00a3609, 143 annually at 2, 136 referrals. CASQ sensitivity met the specified 90% sensitivity threshold in 75.0% of simulations. The mean projected false-negative rate was 9.4 per 1, 000 referrals.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The CASQ-first pathway may reduce assessment costs and redirect a substantial proportion of referrals away from a direct full ADHD assessment, but the present validation study is not adequately powered to support a definitive economic conclusion. Because the economic result rests on a sensitivity estimate derived from only six confirmed ADHD cases, the projected per-referral and national savings are illustrative planning estimates and not established savings. The economic estimates presented here are preliminary and conditional and should be regarded as a commissioning planning aid that becomes interpretable only when independent multi-site validation has established a reliable diagnostic safety margin. Decision-makers should weigh the estimated per-referral cost reduction against diagnostic accuracy uncertainty and potential harm to missed cases. Independent multi-site replication with formal non-inferiority testing is required before unconditional cost-minimisation conclusions can be drawn.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpsyt.2026.1884417","type":"journal-article","created":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T16:13:28Z","timestamp":1785773608000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Cost-consequence analysis of a criterion-based screening and triage pathway compared with full ADHD assessment for adults referred to NHS secondary care"],"prefix":"10.3389","volume":"17","author":[{"given":"Marios","family":"Adamou","sequence":"first","affiliation":[{"name":"School of Human and Health Sciences, University of Huddersfield","place":["Huddersfield, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ellen","family":"Wright","sequence":"additional","affiliation":[{"name":"South West Yorkshire Partnership Teaching National Health Service (NHS) Foundation Trust","place":["Wakefield, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,8,3]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1192\/bjb.2023.88","article-title":"UK adult ADHD services in crisis","volume":"48","author":"Smith","year":"2024","journal-title":"BJPsych Bull"},{"key":"B2","doi-asserted-by":"publisher","DOI":"10.1017\/S003329170500471X","article-title":"The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies","volume":"36","author":"Faraone","year":"2006","journal-title":"Psychol Med"},{"key":"B3","doi-asserted-by":"publisher","DOI":"10.1192\/bjp.bp.107.048827","article-title":"Prevalence and correlates of adult attention-deficit\/hyperactivity disorder: meta-analysis","volume":"194","author":"Simon","year":"2009","journal-title":"Br J Psychiatry"},{"key":"B4","doi-asserted-by":"publisher","article-title":"Independent review into mental health conditions, ADHD and autism: interim report","year":"2026","DOI":"10.1007\/978-94-011-2638-0_3"},{"key":"B5","article-title":"ADHD management information: February 2026","year":"2026"},{"key":"B6","doi-asserted-by":"publisher","first-page":"97","DOI":"10.1017\/S0033291706008713","article-title":"Functional and psychosocial impairment in adults with undiagnosed ADHD","volume":"37","author":"Able","year":"2007","journal-title":"Psychol Med"},{"key":"B7","doi-asserted-by":"publisher","DOI":"10.1017\/S1092852900014036","article-title":"Unrecognized attention-deficit\/hyperactivity disorder in adults presenting with other psychiatric disorders","volume":"13","author":"Barkley","year":"2008","journal-title":"CNS Spectr"},{"key":"B8","doi-asserted-by":"publisher","first-page":"24","DOI":"10.1080\/10550490601082767","article-title":"Substance use among ADHD adults: implications of late onset and subthreshold diagnoses","volume":"16","author":"Faraone","year":"2007","journal-title":"Am J Addict"},{"key":"B9","doi-asserted-by":"publisher","DOI":"10.4088\/PCC.13r01600","article-title":"Underdiagnosis of attention-deficit\/hyperactivity disorder in adult patients: a review of the literature","volume":"16","author":"Ginsberg","year":"2014","journal-title":"Prim Care Companion CNS Disord"},{"key":"B10","doi-asserted-by":"publisher","DOI":"10.1093\/fampra\/cmac038","article-title":"The need for earlier recognition of attention deficit hyperactivity disorder in primary care","volume":"39","author":"Long","year":"2022","journal-title":"Fam Pract"},{"key":"B11","doi-asserted-by":"publisher","DOI":"10.7759\/cureus.19615","article-title":"The burden of undiagnosed adults with attention-deficit\/hyperactivity disorder symptoms in Japan: a cross-sectional study","volume":"13","author":"Naya","year":"2021","journal-title":"Cureus"},{"key":"B12","doi-asserted-by":"publisher","first-page":"38","DOI":"10.1080\/08039480500520665","article-title":"ADHD in adults: a study of clinical characteristics, impairment and comorbidity","volume":"60","author":"Torgersen","year":"2006","journal-title":"Nord J Psychiatry"},{"key":"B13","doi-asserted-by":"publisher","first-page":"195","DOI":"10.1185\/030079904X20303","article-title":"Costs of attention deficit-hyperactivity disorder in the US: excess costs of persons with ADHD and their family members in 2000","volume":"21","author":"Birnbaum","year":"2005","journal-title":"Curr Med Res Opin"},{"key":"B14","doi-asserted-by":"publisher","first-page":"990","DOI":"10.1016\/j.jaac.2012.07.008","article-title":"Economic impact of childhood and adult attention-deficit\/hyperactivity disorder in the United States","volume":"51","author":"Doshi","year":"2012","journal-title":"J Am Acad Child Adolesc Psychiatry"},{"key":"B15","doi-asserted-by":"publisher","first-page":"80","DOI":"10.18553\/jmcp.2021.21290","article-title":"Economic burden of attention-deficit\/hyperactivity disorder among adults in the United States: a societal perspective","volume":"28","author":"Gagnon-Sanschagrin","year":"2022","journal-title":"J Manag Care Spec Pharm"},{"key":"B16","doi-asserted-by":"publisher","DOI":"10.1186\/1478-7547-3-5","article-title":"A review of the economic burden of ADHD","volume":"3","author":"Matza","year":"2005","journal-title":"Cost Eff Resour Alloc"},{"key":"B17","doi-asserted-by":"publisher","first-page":"27","DOI":"10.1186\/s13561-019-0240-z","article-title":"Cost effectiveness of optimal treatment of ADHD in Israel","volume":"9","author":"Ornoy","year":"2019","journal-title":"Health Econ Rev"},{"key":"B18","doi-asserted-by":"publisher","DOI":"10.1007\/s11606-023-08075-w","article-title":"Medical expenditures associated with attention-deficit\/hyperactivity disorder among adults in the United States","volume":"38","author":"Witrick","year":"2023","journal-title":"J Gen Intern Med"},{"key":"B19","doi-asserted-by":"publisher","first-page":"214","DOI":"10.1186\/s12888-018-1792-x","article-title":"The economic consequences of attention-deficit hyperactivity disorder in the Scottish prison system","volume":"18","author":"Young","year":"2018","journal-title":"BMC Psychiatry"},{"key":"B20","doi-asserted-by":"publisher","DOI":"10.1177\/27546330241242873","article-title":"Healthcare resource utilisation and associated costs of adult attention deficit hyperactivity disorder in England","volume":"2","author":"Adamou","year":"2024","journal-title":"Neurodiversity"},{"key":"B21","doi-asserted-by":"publisher","DOI":"10.3389\/fpsyt.2026.1789686","article-title":"Validation of a criterion-based screening and triage pathway for adult ADHD: a prospective observational study of safety and operational efficiency","volume":"17","author":"Adamou","year":"2026","journal-title":"Front Psychiatry"},{"key":"B22","doi-asserted-by":"publisher","DOI":"10.1093\/med\/9780198739258.003.0033","article-title":"Diagnostic interview for ADHD in adults 2.0","author":"Kooij","year":"2010"},{"key":"B23","article-title":"2026\/27 NHS payment scheme: attention-deficit\/hyperactivity disorder and autism payment guidance","year":"2026"},{"key":"B24","volume-title":"Unit Costs of Health and Social Care 2024 Manual","author":"Jones","year":"2025"},{"key":"B25","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1016\/j.jval.2021.11.1351","article-title":"Consolidated health economic evaluation reporting standards 2022 statement","volume":"25","author":"Husereau","year":"2022","journal-title":"Value Health"},{"key":"B26","article-title":"NICE technology appraisal and highly specialised technologies guidance: the manual","year":"2022"},{"key":"B27","doi-asserted-by":"publisher","first-page":"13","DOI":"10.1016\/j.jval.2018.10.001","article-title":"Identifying the need for good practices in health technology assessment","volume":"22","author":"Kristensen","year":"2019","journal-title":"Value Health"},{"key":"B28","doi-asserted-by":"publisher","DOI":"10.3389\/fpsyt.2024.1380410","article-title":"The adult ADHD assessment quality assurance standard","volume":"15","author":"Adamou","year":"2024","journal-title":"Front Psychiatry"},{"key":"B29","volume-title":"Diagnostic and Statistical Manual of Mental Disorders","year":"2013"},{"key":"B30","doi-asserted-by":"publisher","DOI":"10.1002\/hec.584","article-title":"The death of cost-minimization analysis","volume":"10","author":"Briggs","year":"2001","journal-title":"Health Econ"},{"key":"B31","doi-asserted-by":"publisher","first-page":"22","DOI":"10.1002\/hec.1812","article-title":"Cost-minimisation analysis versus cost-effectiveness analysis, revisited","volume":"22","author":"Dakin","year":"2013","journal-title":"Health Econ"},{"key":"B32","volume-title":"Methods for the Economic Evaluation of Health Care Programmes","author":"Drummond","year":"2015"},{"key":"B33","article-title":"Towards clinically interpretable AI in psychiatry for profile complexity: stratification of adult ADHD using explainable clustering","author":"Shakeel","year":""},{"key":"B34","doi-asserted-by":"publisher","DOI":"10.1176\/appi.ajp.163.4.716","article-title":"The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey replication","volume":"163","author":"Kessler","year":"2006","journal-title":"Am J Psychiatry"},{"key":"B35","doi-asserted-by":"crossref","DOI":"10.1093\/oso\/9780198526629.001.0001","volume-title":"Decision Modelling for Health Economic Evaluation","author":"Briggs","year":"2006"},{"key":"B36","doi-asserted-by":"publisher","DOI":"10.36469\/jheor.2024.121305","article-title":"Economic evaluation of a novel treatment of attention-deficit\/hyperactivity disorder in US motor vehicle drivers","volume":"11","author":"Cooper","year":"2024","journal-title":"J Health Econ Outcomes Res"},{"key":"B37","doi-asserted-by":"publisher","DOI":"10.1177\/1087054718799367","article-title":"Health-related quality of life and work productivity of adults with ADHD: a U.K. web-based cross-sectional survey","volume":"23","author":"Joseph","year":"2019","journal-title":"J Atten Disord"},{"key":"B38","first-page":"27","article-title":"The fiscal consequences of ADHD in Germany: a quantitative analysis based on differences in educational attainment and lifetime earnings","volume":"16","author":"Kotsopoulos","year":"2013","journal-title":"J Ment Health Policy Econ"},{"key":"B39","doi-asserted-by":"publisher","DOI":"10.2165\/11592150-000000000-00000","article-title":"Estimation of utilities in attention-deficit hyperactivity disorder for economic evaluations","volume":"4","author":"Lloyd","year":"2011","journal-title":"Patient"},{"key":"B40","article-title":"NHS terms and conditions of service handbook","year":"2026"}],"container-title":["Frontiers in Psychiatry"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpsyt.2026.1884417\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T16:13:30Z","timestamp":1785773610000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpsyt.2026.1884417\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,3]]},"references-count":40,"alternative-id":["10.3389\/fpsyt.2026.1884417"],"URL":"https:\/\/doi.org\/10.3389\/fpsyt.2026.1884417","relation":{},"ISSN":["1664-0640"],"issn-type":[{"value":"1664-0640","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,3]]},"article-number":"1884417"}}