Age-related variation in health service use and associated expenditures among children with autism

Racial Disparities in Hospitalization Due to Ambulatory Care Sensitive Conditions Among U.S. Children with Autism

PURPOSE

This study was to investigate the factors associated with preventable hospitalization due to ambulatory care sensitive conditions (ACSCs) in children with autism.

METHODS

Using secondary data from the U.S. Nationwide Inpatient Sample (NIS), multivariable regression analyses were conducted to determine the potential effect of race and income level on the likelihood of inpatient stays for ACSCs among autistic children. Pediatric ACSCs included three acute conditions (dehydration, gastroenteritis, and urinary infection) and three chronic conditions (asthma, constipation, and diabetes short-term complications).

RESULTS

In this analysis, there were 21,733 hospitalizations among children with autism; about 10% were hospitalized due to pediatric ACSCs. Overall, the odds of ACSCs hospitalization were greater among Hispanic and Black autistic children versus White autistic children. Both Hispanic and Black autistic children from the lowest income level had the highest odds to be hospitalized for chronic ACSCs.

CONCLUSION

Inequities of access to health care among racial/ethnic minorities were most notable for autistic children with chronic ACSC conditions.

Basic Management Strategies by Life Cycle for Treatment of the Persons With Autism Spectrum Disorder

Interventions for targeted symptoms are important when setting treatment strategies for individuals with autism spectrum disorder (ASD) and developmental disabilities. Especially, the goal should be to achieve individual "niche construction" by allowing them to select and adjust an environment where they can demonstrate their special characteristics and strengths. In addition, these choices should vary depending on the stage of development of each person with ASD and developmental disabilities. It is necessary to establish a detailed and systematic plan for diagnosis and treatment necessary for infants and toddlers, school placement in school age, and employment or self-reliance in adult transition period to establish customized treatment strategies that fit the individual level of people with ASD and developmental disabilities.

Community-based care for autistic youth: community providers' reported use of treatment practices in the United States

Introduction

To illustrate the landscape of community-based care for autistic youth in the United States, we identified transdisciplinary psychosocial intervention practice sets that community providers report utilizing to care for this population, and examined characteristics associated with provider-reported utilization.

Methods

The Usual Care for Autism Study (UCAS) Survey assessed provider demographics and provider-reported use of transdisciplinary practices for common ASD co-occurring problems: social difficulties, externalizing behaviors, and anxiety. Community practitioners (N = 701) from allied health, behavioral, education, medical, mental health and other disciplines who treat or work with autistic youth (7-22 years) participated.

Results

Exploratory factor analysis yielded four factors: Consequence-Based Strategies (CBS), Cognitive-Behavioral and Therapy Strategies (CBTS), Antecedent-Based Strategies (ABS), and Teaching Strategies (TS). Providers across disciplines reported utilizing ABS more often than other sets. Providers from behavioral disciplines, with less than 4-year or Master degrees, or with more experience reported the most use of ABS, CBS and CBTS. Medical and behavioral providers reported the most use of TS. Setting and child characteristics were associated with practice set use, indicating variability by disability and client socioeconomic status.

Discussion

Findings reflect the complexity and inconsistency of the service landscape for autistic youth across the U.S. Only by understanding the service landscape and predictors of practice utilization, can researchers, policymakers, provider groups, and the autistic community facilitate effective implementation strategy development and use to ultimately improve community-based care.

Geographic Variation in Preventable Hospitalizations among US Children with Autism

There is a limited amount of research on geographic differences in preventable hospitalizations for ambulatory care sensitive conditions (ACSCs) among children with autism. The purpose of this study was to examine US regional differences in potentially preventable hospital admissions for pediatric inpatients diagnosed with autism. Hospital discharge data for six pediatric preventable conditions were obtained from the 2016-2019 National Inpatient Sample (NIS) under the US Agency for Healthcare Research and Quality. Geographic differences in preventable hospitalizations for children with autism were examined by US census regions and divisions. Multiple logistic regression analyses were conducted to examine child and clinical characteristics associated with ACSCs hospitalization across four US regions; the dependent variable was the likelihood of ACSCs hospitalization. Additionally, this study further explored the variation in preventable hospitalization among racial and ethnic groups for each region or division. Of the 138,305 autistic inpatients aged 2-17 years, about 10% had a primary diagnosis related to ACSCs. The results showed that the highest proportion of preventable hospitalizations for autistic children occurred in the middle Atlantic division of the northeast region. Racial differences were observed across all US regions, particularly in the northeast and south regions. Black children with autism were more likely to be hospitalized for ACSCs compared to White children with autism in three of the four US regions. Our results highlight the significant racial disparities in potentially avoidable hospitalizations among US children with autism. Examining geographic and racial differences in potentially avoidable hospitalizations could inform policy and practice while gaining a better understanding of pediatric patients with autism and where their families access health services. The findings of this study may help policymakers to identify where intervention is needed to tackle health inequities in the accessibility to quality primary care in the US. Further studies with more detailed investigation are recommended to better understand the mechanisms underlying these disparities, and to formulate effective regional policy and clinical practices while considering the unique needs and challenges of underserved children with autism.

Health conditions in autism: Defining the trajectory from adolescence to early adulthood

Autistic adults, as compared to non-autistic adults, have increased rates of nearly all medical and psychiatric conditions. Many of these conditions begin in childhood, although few longitudinal studies have been conducted to examine prevalence rates of these conditions from adolescence into early adulthood. In this study, we analyze the longitudinal trajectory of health conditions in autistic youth, compared to age and sex-matched non-autistic youth, transitioning from adolescence into early adulthood in a large integrated health care delivery system. The percent and modeled prevalence of common medical and psychiatric conditions increased from age 14 to 22 years, with autistic youth having a higher prevalence of most conditions than non-autistic youth. The most prevalent conditions in autistic youth at all ages were obesity, neurological disorders, anxiety, and ADHD. The prevalence of obesity and dyslipidemia rose at a faster rate in autistic youth compared to non-autistic youth. By age 22, autistic females showed a higher prevalence of all medical and psychiatric conditions compared to autistic males. Our findings emphasize the importance of screening for medical and psychiatric conditions in autistic youth, coupled with health education targeted at this population, to mitigate the development of adverse health outcomes in autistic adults.

Community-based postural control assessment in autistic individuals indicates a similar but delayed trajectory compared to neurotypical individuals

Autistic individuals exhibit significant sensorimotor differences. Postural stability and control are foundational motor skills for successfully performing many activities of daily living. In neurotypical development, postural stability and control develop throughout childhood and adolescence. In autistic development, previous studies have focused primarily on individual age groups (e.g., childhood, adolescence, adulthood) or only controlled for age using age-matching. Here, we examined the age trajectories of postural stability and control in autism from childhood through adolescents using standardized clinical assessments. In study 1, we tested the postural stability of autistic (n = 27) and neurotypical (n = 41) children, adolescents, and young adults aged 7-20 years during quiet standing on a force plate in three visual conditions: eyes open (EO), eyes closed (EC), and eyes open with the head in a translucent dome (Dome). Postural sway variability decreased as age increased for both groups, but autistic participants showed greater variability than neurotypical participants across age. In study 2, we tested autistic (n = 21) and neurotypical (n = 32) children and adolescents aged 7-16 years during a dynamic postural control task with nine targets. Postural control efficiency increased as age increased for both groups, but autistic participants were less efficient compared to neurotypical participants across age. Together, these results indicate that autistic individuals have a similar age trajectory for postural stability and control compared to neurotypical individuals, but have lower postural stability and control overall.

A cross-sectional examination of service complexity in youths with co-occurring autism spectrum disorder and psychiatric or medical diagnoses across service sectors

Introduction

Autism spectrum disorder (ASD) is a heterogeneous, life-long, and complex condition. Youth diagnosed with ASD require several supports addressing core symptoms associated with the disorder, but also those resulting from co-occurring mental and physical health conditions. As a result, their care is overseen by numerous professionals spanning various service sectors, but communication between sectors is hindered due to the absence of a standardized assessment system to identify and triage youth to services. A paucity of information surrounding this population's service use lingers and a siloed delivery system persists.

Methods

Using archival data collected from 1,020 youth between 12 and 18 years of age, this study explored service complexity among autistic youth with and without psychiatric and medical co-occurring conditions in Ontario, Canada. In doing so, a negative binomial regression was utilized to investigate which predisposing, enabling, and need variables were associated with service complexity.

Results

Results revealed that experiencing financial difficulties was not associated with service complexity. However, age, sex, caregiver distress, comorbidity, intellectual disability, and evaluated health status were significant predictors. More specifically, female youth and youth with distressed caregivers had greater mental health service complexity scores. Additionally, youth diagnosed with two or more conditions in addition to ASD who required longer durations of programming, controlling for other predictors, had greater mental health service complexity scores. Yet, youth with an intellectual disability had lower service complexity scores.

Discussion

Clinical implications of this study are discussed to inform future investments into mental health efforts for autistic youth.

Heterogeneity in Autism Spectrum Disorder Case-Finding Algorithms in United States Health Administrative Database Analyses

Strengthening systems of care to meet the needs of individuals with autism spectrum disorder (ASD) is of growing importance. Administrative data provide advantages for research and planning purposes, including large sample sizes and the ability to identify enrollment in insurance coverage and service utilization of individuals with ASD. Researchers have employed varying strategies to identify individuals with ASD in administrative data. Differences in these strategies can limit the comparability of results across studies. This review describes implications of the varying strategies that have been employed to identify individuals with ASD in US claims databases, with consideration of the strengths and limitations of each approach.

Medicaid Disruption Among Transition-Age Youth on the Autism Spectrum

Enrollment in Medicaid facilitates access to needed services among transition-age youth on the autism spectrum and youth with intellectual disability (ID). There are long-standing programs to ensure that individuals with ID remain enrolled as they age; similar programs for autistic youth are newer, not as widespread, and may not be as effective. We compared Medicaid disenrollment and re-enrollment between transition-age youth on the autism spectrum, youth with ID, and youth with both diagnoses using a national claims-based prospective cohort study from 2008 through 2012. Autistic youth were most likely to disenroll and least likely to re-enroll. Disenrollment peaked for all three groups at ages 19 and 21. Transition-age youth on the autism spectrum experience more disruptions in access to Medicaid-reimbursed services than youth with ID. More equitable Medicaid enrollment options for autistic individuals are needed to ensure their access to critical health care as they age.

Lifespan service receipt and unmet needs among individuals on the autism spectrum

Timely data on service use and needs across the lifespan are essential to developing an effective and efficient service delivery system that is responsive to developmental issues. This study uses data from one of the largest statewide surveys conducted between 2017 and 2018 to compare service use and unmet needs among individuals on the autism spectrum across the lifespan. A statewide sample of 5792 caregivers of autistic children and adults were included in the study. Logistic regressions were conducted to compare service use and need among six age groups ranging from early childhood (0-5 years) to later adulthood (31+) while adjusting for sociodemographic characteristics. We found that the transition-age adult group (18-21 years) was less likely to receive services, including speech/language therapy, occupational therapy, one-on-one support, and social skill training, than adolescents. However, case management and mental health services increased with age. Young adults (22-30 years) were more likely to report unmet needs than both adolescents and transition-age adult groups. The use of services overall decrease and service needs increased compared to results from an earlier statewide survey that was conducting in 2009-2010. These results can be used to inform developmentally appropriate autism-related healthcare policies and service development and delivery. This study offers a more detailed look at differences between adult age subgroups that are novel. Further research is needed about the prevalence of ASD in adulthood, clinical trajectories, and outcomes in order to support autistic adults in getting the appropriate services and supports.

"We are doing the best we can to bridge the gap" - service provider perspectives of educational services for autism spectrum disorder in South Africa

BACKGROUND

The South African education system is increasingly unable to meet the growing needs of children with autism spectrum disorder (ASD). Recent studies in the Western Cape, one of the better resourced provinces in South Africa, showed that the pathway to care for children with ASD was an inconsistent and lengthy process, and that many children with ASD waited for extended periods to get access to an appropriate school placement. It is therefore clear that scalable and sustainable solutions are required to improve access to appropriate education for children with ASD.

METHODS

Here we performed a qualitative study using thematic analysis of ten multi-sectorial ASD service provider interviews in the Western Cape Province to examine provider perspectives and proposed solutions to meet the educational needs of children with ASD.

RESULTS

Provider perspectives were grouped in three categories: "bridging the gap across the spectrum and lifespan", "gaps to bridge", and "building bridges". The first category captured provider perspectives of the service-related needs inherent to a diagnosis of ASD. The second category summarized service provider views of the challenges associated with providing services to children with ASD and the third category captured provider perspectives on potential actions to improve ASD education services delivery in the province. The overarching theme that emerged was "We're doing the best we can to bridge the gap".

CONCLUSION

Participants provided ten key recommendations for service strengthening that may lead to contextually relevant innovations to meet the educational needs of children with ASD in the province. Findings from this study has direct relevance to other South African provinces and may have relevance to improve pathways and reduce service delivery gaps also in other low-and-middle-income countries.

Occupational Therapy Service Delivery Among Medicaid-Enrolled Children and Adults on the Autism Spectrum and With Other Intellectual Disabilities

IMPORTANCE

Rates of occupational therapy service utilization among people with autism spectrum disorder (ASD) or intellectual disability (ID) have not been explored in population-based samples.

OBJECTIVE

To describe occupational therapy services delivered to Medicaid-eligible persons younger than age 65 yr identified as having ASD, ID, or both and to evaluate demographic factors associated with occupational therapy service utilization in this population.

DESIGN

Retrospective, case-control, cohort study using claims records from Medicaid Analytic eXtract files (2009-2012).

SETTING

Data from all 50 states and Washington, DC.

PARTICIPANTS

Beneficiaries identified as having ASD only, ASD+ID, or ID only who were younger than age 18 yr (N = 664,214) and ages 18-64 yr (N = 702,338). Outcomes and Measures: We analyzed Current Procedural Terminology® and Healthcare Common Procedure Coding System procedure codes, Medicaid Statistical Information System type of service codes, and Center for Medicare & Medicaid Services provider specialty codes.

RESULTS

Only 3.7% to 6.3% of eligible adult beneficiaries received occupational therapy; in contrast, 20.5% to 24.2% of children received occupational therapy. Significant predictors of service use varied by group; however, differences by race-ethnicity, eligibility on the basis of poverty, and geographic location were observed. Among children, the most frequent billing code was for "therapeutic activities" (43%-60%); among adults, it was "community/work reintegration training" (29%-39%).

CONCLUSIONS AND RELEVANCE

Billed procedure code patterns do not consistently reflect the unique occupational focus that occupational therapy providers deliver to people with developmental disabilities. Disparities in occupational therapy receipt warrant further attention to understand the social and structural factors affecting service delivery. What This Article Adds: Occupational therapy services paid for by Medicaid are used more frequently by children with ASD and ID than by adults with these diagnoses. Greater understanding of the intersectional factors that drive service delivery and disparities is needed.

COVID-19 Pandemic and Impact on Patients with Autism Spectrum Disorder

The COVID-19 infectious disease pandemic has caused significant fear and uncertainty around the world and had significant adverse psychological impact. Children, adolescents and adults with autism spectrum disorder (ASD) are a particularly vulnerable population, impacted by stay-at-home orders, closures at nonessential services, and social distancing standards. This commentary describes various challenges faced by individuals with ASD in the United States including disruptions caused by educational and vocational changes, challenges to home and leisure routines, limited access to behavioral health services and changes in health services delivery due to the pandemic. We highlight the need for ongoing skills development for individuals and development within systems to better respond to needs of the ASD population in future emergencies.

A Systematic Review on the Impact of the Social Confinement on People with Autism Spectrum Disorder and Their Caregivers during the COVID-19 Pandemic

The COVID-19 pandemic had imposed a variety of containment measures on the general population for prolonged periods. Confinement has had, and still has, social, economic, educational, health, and psychological consequences on the entire population.

OBJECTIVE

In this article, a systematic search has been performed based on studies carried out since the beginning of the pandemic, regarding the impact of these containment measures on the autism spectrum disorder (ASD) population and their caregivers.

METHOD

We consulted six databases (i.e., PubMed, Medline, Embase, Scopus, Web of Science, and Science Direct) and selected ten studies that met the inclusion criteria. The chosen studies have been classified according to their theoretical focus, methodology, and target population.

RESULTS

We found an increase in stress and a decrease in psychological well-being among individuals diagnosed with ASD (i.e., parents and caregivers). Additionally, in studies focused on children, youth, and adults with ASD diagnosis, the results are contradictory depending on variables such as age, ASD severity, or type of family structure.

CONCLUSIONS

The results show that the consequences of quarantine and social confinement are quite contradictory and depend on variables such as age, ASD severity, and family features.

Assessing the Healthy People 2020 Objective to Expand Early Treatment Receipt Among a National Sample of Children with Autism Spectrum Disorder

OBJECTIVE

To assess the progress of the Healthy People 2020 (HP2020) objective to increase the proportion of children with autism spectrum disorder (ASD) who receive treatment by 48 months old and to examine the relationship between predisposing, enabling, and need factors and age of initial treatment receipt.

METHOD

We used data from the National Survey of Children's Health, 2016 to 2017, a nationally representative study of US children. Our sample included children aged 3 to 17 years old with ASD who received treatment (N = 1333). We conducted χ goodness of fit tests and logistic regression.

RESULTS

The HP2020 objective to enroll 57.6% of 8-year-old children with ASD in treatment by 48 months old was not met (40.9%). Among 3- to 5-year-old children with ASD, the proportion who received treatment by 48 months old was more than double that of 8-year-old children (88.3%). We detected social inequities and significant differences by provider type and state mandate.

CONCLUSION

Research with larger samples is needed to continue tracking progress. If the goal continues not to be met, work will be required to explain stagnation and to inform additional targeted efforts to reduce the age of initial treatment.

Parental perspectives on support needs and availability of autism services in South and South-Eastern Europe

Purpose

Amid the expanding demand on the autism service delivery system, little knowledge is accumulated regarding access and availability of support and services in the region of Southern and South-Eastern Europe – critical for improvement of individual outcomes, as well as family quality of life. The purpose of this paper is to explore how service delivery systems are responding to the specific needs of autistic individuals with autism, as perceived by parents.

Design/methodology/approach

A qualitative exploratory descriptive method was used. Thematic analysis was used as a pragmatic method to report on the experiences of parents (92% mothers, n = 55) of children, youth and young autistic adults (76% male) across six South and South-Eastern European counties that participated in a survey involving a combination of qualitative and quantitative data collection.

Findings

Thematic analysis revealed three broad themes: challenging pathways to service utilization, insufficient service options and providers’ competences and lack of continuous and meaningful support across life span.

Originality/value

The findings from this study add to the small body of literature specific to South and South-Eastern Europe, by exposing problems related to meeting the needs of autistic children and youth and potential ways to strengthen services, as perceived by parents. The findings have potential policy ramifications for the region in which the research was conducted.

Facilitators and barriers to the utilization of the ACT SMART Implementation Toolkit in community-based organizations: a qualitative study

BACKGROUND

Evidence-based practices (EBPs) have been shown to improve behavioral and mental health outcomes for children diagnosed with autism spectrum disorder (ASD). Research suggests that the use of these practices in community-based organizations is varied; however, the utilization of implementation guides may bridge the gap between research and practice. The Autism Community Toolkit: Systems to Measure and Adopt Research-Based Treatments (ACT SMART) Implementation Toolkit is a web-based implementation toolkit developed to guide organization-based implementation teams through EBP identification, adoption, implementation, and sustainment in ASD community-based organizations.

METHODS

This study examined the facilitators and barriers (collectively termed "determinants") to the utilization of this toolkit, based on the perspectives of implementation teams at six ASD community-based organizations. Two independent coders utilized the adapted EPIS framework and the Technology Acceptance Model 3 to guide qualitative thematic analyses of semi-structured interviews with implementation teams.

RESULTS

Salient facilitators (e.g., facilitation teams, facilitation meetings, phase-specific activities) and barriers (e.g., website issues, perceived lack of ease of use of the website, perceived lack of resources, inner context factors) were identified, highlighting key determinants to the utilization of this toolkit. Additionally, frequent determinants and determinants that differed across adapted EPIS phases of the toolkit were noted. Finally, analyses highlighted two themes: (a) Inner Context Determinants to use of the toolkit (e.g., funding) and (b) Innovation Determinants (e.g., all website-related factors), indicating an interaction between the two models utilized to guide study analyses.

CONCLUSIONS

Findings highlighted several factors that facilitated the utilization of this implementation guide. Additionally, findings identified key areas for improvement for future iterations of the ACT SMART Implementation Toolkit. Importantly, these results may inform the development, refinement, and utilization of implementation guides with the aim of increasing the uptake of EBPs in community-based organizations providing services to children with ASD and their families. Finally, these findings contribute to the implementation science literature by illustrating the joint use of the EPIS framework and Technology Acceptance Model 3 to evaluate the implementation of a web-based toolkit within community-based organizations.

Racial and ethnic disparities in benefits eligibility and spending among adults on the autism spectrum: A cohort study using the Medicare Medicaid Linked Enrollees Analytic Data Source

BACKGROUND

Research on children and youth on the autism spectrum reveal racial and ethnic disparities in access to healthcare and utilization, but there is less research to understand how disparities persist as autistic adults age. We need to understand racial-ethnic inequities in obtaining eligibility for Medicare and/or Medicaid coverage, as well as inequities in spending for autistic enrollees under these public programs.

METHODS

We conducted a cross-sectional cohort study of U.S. publicly-insured adults on the autism spectrum using 2012 Medicare-Medicaid Linked Enrollee Analytic Data Source (n = 172,071). We evaluated differences in race-ethnicity by eligibility (Medicare-only, Medicaid-only, Dual-Eligible) and spending.

FINDINGS

The majority of white adults (49.87%) were full-dual eligible for both Medicare and Medicaid. In contrast, only 37.53% of Black, 34.65% Asian/Pacific Islander, and 35.94% of Hispanic beneficiaries were full-dual eligible for Medicare and Medicare, with most only eligible for state-funded Medicaid. Adjusted logistic models controlling for gender, intellectual disability status, costly chronic condition, rural status, county median income, and geographic region of residence revealed that Black beneficiaries were significantly less likely than white beneficiaries to be dual-eligible across all ages. Across these three beneficiary types, total spending exceeded $10 billion. Annual total expenditures median expenditures for full-dual and Medicaid-only eligible beneficiaries were higher among white beneficiaries as compared with Black beneficiaries.

CONCLUSIONS

Public health insurance in the U.S. including Medicare and Medicaid aim to reduce inequities in access to healthcare that might exist due to disability, income, or old age. In contrast to these ideals, our study reveals that racial-ethnic minority autistic adults who were eligible for public insurance across all U.S. states in 2012 experience disparities in eligibility for specific programs and spending. We call for further evaluation of system supports that promote clear pathways to disability and public health insurance among those with lifelong developmental disabilities.

Systematic Review of Disparities and Differences in the Access and Use of Allied Health Services Amongst Children with Autism Spectrum Disorders

Individuals with autism spectrum disorder (ASD) often benefit from allied health services such as occupational therapy, speech and language pathology, and applied behavioral analysis. While there is consistent evidence of disparities in access and use of medical services (e.g. dentistry), no such systematic review has examined disparities and differences in allied health use amongst children with ASD. In this systematic review, we examine disparities and differences in service access and use for children with ASD. Our findings suggest that children who are older, have less severe ASD symptoms, are from minority groups, and those from particular geographic regions are less likely to receive allied health services. Limitations and future directions are discussed.

Health Services Use and Costs in Individuals with Autism Spectrum Disorder in Germany: Results from a Survey in ASD Outpatient Clinics

Autism spectrum disorders (ASD) are associated with high services use, but European data on costs are scarce. Utilisation and annual costs of 385 individuals with ASD (aged 4–67 years; 18.2% females; 37.4% IQ < 85) from German outpatient clinics were assessed. Average annual costs per person were 3287 EUR, with psychiatric inpatient care (19.8%), pharmacotherapy (11.1%), and occupational therapy (11.1%) being the largest cost components. Females incurred higher costs than males (4864 EUR vs. 2936 EUR). In a regression model, female sex (Cost Ratio: 1.65), lower IQ (1.90), and Asperger syndrome (1.54) were associated with higher costs. In conclusion, ASD-related health costs are comparable to those of schizophrenia, thus underlining its public health relevance. Higher costs in females demand further research.

Brief Report: Impact of COVID-19 on Individuals with ASD and Their Caregivers: A Perspective from the SPARK Cohort

The impact of the 2019 coronavirus pandemic (COVID-19) in the United States is unprecedented, with unknown implications for the autism community. We surveyed 3502 parents/caregivers of individuals with an autism spectrum disorder (ASD) enrolled in Simons Powering Autism Research for Knowledge (SPARK) and found that most individuals with ASD experienced significant, ongoing disruptions to therapies. While some services were adapted to telehealth format, most participants were not receiving such services at follow-up, and those who were reported minimal benefit. Children under age five had the most severely disrupted services and lowest reported benefit of telehealth adaptation. Caregivers also reported worsening ASD symptoms and moderate family distress. Strategies to support the ASD community should be immediately developed and implemented.

Spending on Young Children With Autism Spectrum Disorder in Employer-Sponsored Plans, 2011-2017

OBJECTIVE

Rapid increases in the prevalence of autism spectrum disorder (ASD) and increased access to intensive behavioral interventions have likely increased health care spending. This study estimated recent changes in spending among privately insured children with and without current ASD.

METHODS

A repeated cross-sections analysis of 2011-2017 claims data from large-employer-sponsored health plans assessed changes in annual expenditures by service type for children ages 3-7 enrolled for ≥1 year and with two or more claims with ASD billing codes within a calendar year and for all other children.

RESULTS

Mean spending per child with a current-year ASD diagnosis increased by 51% in 2017 U.S. dollars, from roughly $13,000 in 2011 to $20,000 in 2017. Among children who did not meet the current-year ASD case definition, per-child spending increased by 8%. Spending on children with ASD accounted for 41% of spending growth for children ages 3-7 during 2011-2017. Outpatient behavioral intervention-related spending per child with ASD increased by 376%, from $1,746 in 2011 to $8,317 in 2017; spending on all other services increased by 2%. Their share of behavioral intervention-related spending increased from 13.2% in 2011 to 41.7% in 2017. In 2011, 2.5% of children with current-year ASD diagnoses incurred ≥$20,000 in outpatient behavioral intervention-related spending, which increased to 14.4% in 2017.

CONCLUSIONS

During 2011-2017, spending increased six times as much for privately insured children ages 3-7 with current-year ASD as for children without ASD, largely from increased behavioral intervention-related spending. One in seven children received at least $20,000 in services in 2017.

The Safety and Effectiveness of High-Dose Propranolol as a Treatment for Challenging Behaviors in Individuals With Autism Spectrum Disorders

PURPOSE/BACKGROUND

Individuals with autism spectrum disorders present with social communication deficits and a rigid adherence to sameness. Along with these symptoms, many individuals also present with severe challenging behaviors that place themselves as well as their families and communities at risk for injury. For these individuals, new and effective treatments are acutely needed. Propranolol has been used worldwide for over 50 years. Its primary indication is for hypertension, but there is evidence that, at higher doses, propranolol inhibits rage and anger through its effects on the central nervous system. This effect has been demonstrated in a variety of neuropsychiatric disorders.

METHODS/PROCEDURES

Here, we present 46 retrospective analyses of clinical cases that were followed by a psychiatrist. Propranolol was prescribed as an add-on to the patients' existing medications. The doses ranged from 120 to 960 mg per day (mean = 462 mg).

FINDINGS/RESULTS

Thirty-nine (85%) of 46 patients were found to be much improved or very much improved on the physician-rated Clinical Global Impression Improvement scale. There were few side effects noted, with only 2 subjects unable to tolerate the propranolol.

IMPLICATIONS/CONCLUSIONS

It appears that high-dose propranolol can be given safely with minimal adverse cardiovascular problems, provided that close clinical monitoring is maintained. A more rigorous clinical trial is needed to elucidate and verify its clinical utility, clinical practice parameters, and the effects of propranolol as a monotherapy versus as an add-on to the patient's existing medication regimen.

Healthcare Costs of Pediatric Autism Spectrum Disorder in the United States, 2003-2015

Published healthcare cost estimates for children with autism spectrum disorder (ASD) vary widely. One possible contributor is different methods of case ascertainment. In this study, ASD case status was determined using two sources of parent reports among 45,944 children ages 3-17 years in the Medical Expenditure Panel Survey (MEPS) linked to the National Health Interview Survey (NHIS) Sample Child Core questionnaire. In a two-part regression model, the incremental annual per-child cost of ASD relative to no ASD diagnosis was $3930 (2018 US dollars) using ASD case status from the NHIS Child Core and $5621 using current-year ASD case status from MEPS. Both estimates are lower than some published estimates but still represent substantial costs to the US healthcare system.

Cross-sector service use patterns among children with developmental disabilities in a district in Canada

BACKGROUND

There is a lack of information about cross-sector service use by children with developmental disabilities despite their need for services from multiple sectors.

METHODS

Responses to service use questions from a parent-completed survey on school-aged children who attended clinics specific for those with developmental disabilities at a Canadian children's hospital were examined.

RESULTS

School meetings were the most common of three professional meeting types attended in the last 12 months (64.9%) for the sample of 205 children. Recreational services were the most common of five service types received in the same time period (79.0%). Using ordinal logistic regression models, a higher number of behavioural difficulties was the only variable consistently related to indices of more meeting types (school, physician, other) attended and more service types received (recreation, respite, etc.).

CONCLUSIONS

The service relationship with behavioural problems, and not socio-demographic variables, is consistent with a needs-based oriented delivery system.

Health system utilization before age 1 among children later diagnosed with autism or ADHD

Children with autism spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD) have 2-3 times increased healthcare utilization and annual costs once diagnosed, but little is known about their utilization patterns early in life. Quantifying their early health system utilization could uncover condition-specific health trajectories to facilitate earlier detection and intervention. Patients born 10/1/2006-10/1/2016 with ≥ 2 well-child visits within the Duke University Health System before age 1 were grouped as ASD, ADHD, ASD + ADHD, or No Diagnosis using retrospective billing codes. An additional comparison group was defined by later upper respiratory infection diagnosis. Adjusted odds ratios (AOR) for hospital admissions, procedures, emergency department (ED) visits, and outpatient clinic encounters before age 1 were compared between groups via logistic regression models. Length of hospital encounters were compared between groups via Mann-Whitney U test. In total, 29,929 patients met study criteria (ASD N = 343; ADHD N = 1175; ASD + ADHD N = 140). ASD was associated with increased procedures (AOR = 1.5, p < 0.001), including intubation and ventilation (AOR = 2.4, p < 0.001); and outpatient specialty care, including physical therapy (AOR = 3.5, p < 0.001) and ophthalmology (AOR = 3.1, p < 0.001). ADHD was associated with increased procedures (AOR = 1.41, p < 0.001), including blood transfusion (AOR = 4.7, p < 0.001); hospital admission (AOR = 1.60, p < 0.001); and ED visits (AOR = 1.58, p < 0.001). Median length of stay was increased after birth in ASD (+ 6.5 h, p < 0.001) and ADHD (+ 3.8 h, p < 0.001), and after non-birth admission in ADHD (+ 1.1 d, p < 0.001) and ASD + ADHD (+ 2.4 d, p = 0.003). Each condition was associated with increased health system utilization and distinctive patterns of utilization before age 1. Recognizing these patterns may contribute to earlier detection and intervention.

Autism Prevalence in the Medicaid Program and Healthcare Utilization and Costs Among Adult Enrollees Diagnosed with Autism

As the number of individuals diagnosed with autism increases, there is an increase in demand to provide support throughout their lifespan. This study aimed to: (1) estimate trends in the prevalence of autism diagnoses and medical services use in adults with autism diagnoses; (2) assess predictors of healthcare utilization and costs among adults with autism diagnoses enrolled in Medicaid. A retrospective analysis of 2006-2008 Medicaid claims for 39 states was conducted. There was a 38% increase in the prevalence of autism diagnoses from 2006 to 2008. Total expenditures and outpatient and ER visits varied significantly by demographic variables.

Academic achievement and productivity losses associated with speech, language and communication needs

BACKGROUND

Childhood speech, language and communication needs (SLCN) impose a significant burden on individuals, families and society. There are explicit costs related to increased health utilization and expenditure. Additionally, there may be indirect costs associated with a child's employment prospects in the long term because of the child's low literacy and numeracy, which in turn affects adult labour force participation (LFP). Several reviews have identified that there is paucity of published evidence on the costs of SLCN. Motivated by broad policy implications, and the lack of prior research in this area, this paper calculates the indirect costs and workplace productivity losses of children with SLCN.

AIMS

To estimate the indirect costs of SLCN associated with a child's reduced long-term productivity.

METHODS & PROCEDURES

Using 12 years of data from a longitudinal study of Australian children, we employed a panel fixed-effects model to estimate academic achievement at 14-15 years of age. Using these estimates, we employed a human capital approach (HCA) to estimate the projected LFP for children with SLCN, measured by workforce participation and foregone wages. LFP is estimated by extrapolating a child's academic achievement at 14-15 years of age to adulthood outcomes.

OUTCOMES & RESULTS

The results showed that a 1 SD (standard deviation) decrease in SLCN is equivalent to 0.19 (95% confidence interval (CI) = 0.09, 0.30) SD decrease in academic achievement at 14-15 years, 0.79% (95% CI = 0.37, 1.21) decrease in work participation and A$453 (95% CI = A$207, A$674) per annum in lost wages. The average work participation penalty across all level of SLCN (-3, -2, -1) is A$628 (95% CI = A$236, A$894) per person per year. Based on the prevalence of 8.3% from our sample, this equates to lifetime costs of A$21.677 billion (US$14.28 billion, €13.08 billion, £11.66 billion) for children with SLCN in Australia. Speech pathology treatment appears to have a positive impact on work participation and wages. On average A$355 (95% CI = A$346, A$355) per person per year could be saved through treatment or identification (the difference in lost wages for children with and without speech pathology treatment at each SLCN level (-1, -2 ,-3) calculated as a weighted average). This equates to lifetime savings of A$5.22 billion (US$3.44 billion, €3.15 billion, £2.81 billion) for children with SLCN in Australia.

CONCLUSIONS & IMPLICATIONS

Overall, the findings showed that SLCN are associated with increased indirect costs through reduced workforce participation. The evidence from this study can be used to inform policies on the societal costs of SLCN. What this paper adds What is already known on this subject Childhood SLCN impose significant burden on individuals, families and society. There are explicit costs related to increased health utilization and expenditure. Additionally, there may be indirect costs associated with a child's employment prospects in the long term because of the child's low literacy and numeracy, which in turn affects adult LFP. Several reviews have identified that there is paucity of published evidence on the costs of SLCN. Motivated by broad policy implications, and the lack of prior research in this area, this paper calculates the indirect costs and workplace productivity losses of children with SLCN. What this paper adds to existing knowledge This study estimates the academic achievement and indirect costs of SLCN associated with a child's reduced long-term productivity. Using 12 years of data from a longitudinal study of Australian children, we employed a panel fixed-effects model to estimate academic achievement at 14-15 years of age. Using these estimates, we used a human capital approach to estimate the projected LFP for children with SLCN, measured by workforce participation and foregone wages. LFP is estimated by extrapolating a child's academic achievement at 14-15 years of age to adulthood outcomes. What are the potential or actual clinical implications of this work? SLCN are associated with increased indirect costs through reduced workforce participation. The evidence from this study provides one of the first indirect cost estimates of how SLCN impacts LFP through educational achievement. Early identification, intervention and screening for SLCN may be useful offsets to reduce the economic effects identified here.

Is Earlier Better? The Relationship between Age When Starting Early Intervention and Outcomes for Children with Autism Spectrum Disorder: A Selective Review

Although the conventional wisdom is that “earlier is better” when it comes to intervention for children with ASD, it is not clear what evidence exists to support this notion. This review examined a group of studies that addressed outcomes for young children with ASD who started early intervention at a range of ages. The review was selective by including only papers that examined the age of initiation of treatment as well as baseline cognitive, language, or adaptive level and, in addition, employed a method to control for the covariance between early ability level and age of beginning intervention. Fourteen studies were identified and then compared on methods and outcomes. The support for “earlier is better” was mixed, but it was clear that complex relationships among predictor variables need to be explored in order to understand the role of age of starting early intervention for later outcomes.

Service use by youth with autism within a system-driven implementation of evidence-based practices in children's mental health services

Public mental health systems play an important role in caring for youth with autism spectrum disorder. Like other dually diagnosed populations, youth with autism spectrum disorder may receive services in the context of evidence-based practice implementation efforts within public mental health systems. Little is known about service use patterns within the context of system-driven implementations efforts for this population. This case-control study examined mental health service patterns of 2537 youth with autism spectrum disorder compared to 2537 matched peers receiving care in the Los Angeles County Department of Mental Health, the largest public mental health department in the United States, within the context of a system-driven implementation of multiple evidence-based practices. Although not the primary target of this implementation effort, youth with autism spectrum disorder were served when they met criteria for the services based on their presenting mental health symptoms. Comparative analyses using administrative claims data were conducted to examine differences in mental health utilization patterns and clinical characteristics. Findings revealed significant differences in the volume and duration of mental health services as well as differences in the service type and evidence-based practice delivered between youth with and without autism spectrum disorder. Results provide direction targeting implementation efforts for youth with autism spectrum disorder within a public mental health system care reform.

Autism in Adulthood: Clinical and Demographic Characteristics of a Cohort of Five Hundred Persons with Autism Analyzed by a Novel Multistep Network Model

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in communication and relational skills, associated with repetitive verbal and motor behaviors, restricted patterns of interest, need for a predictable and stable environment, and hypo- or hypersensitivity to sensory inputs. Due to the challenging diagnosis and the paucity of specific interventions, persons with autism (PWA) reaching the adult age often display a severe functional regression. In this scenario, the Regional Center for Autism in Adulthood in Turin seeks to develop a personalized rehabilitation and enablement program for PWA who received a diagnosis of autism in childhood/adolescence or for individuals with suspected adulthood ASD. This program is based on a Multistep Network Model involving PWA, family members, social workers, teachers, and clinicians. Our initial analysis of 500 PWA shows that delayed autism diagnosis and a lack of specific interventions at a young age are largely responsible for the creation of a “lost generation” of adults with ASD, now in dire need of effective psychosocial interventions. As PWA often present with psychopathological co-occurrences or challenging behaviors associated with lack of adequate communication and relational skills, interventions for such individuals should be mainly aimed to improve their self-reliance and social attitude. In particular, preparing PWA for employment, whenever possible, should be regarded as an essential part of the intervention program given the social value of work. Overall, our findings indicate that the development of public centers specialized in assisting and treating PWA can improve the accuracy of ASD diagnosis in adulthood and foster specific habilitative interventions aimed to improve the quality of life of both PWA and their families.

Objective Estimates of Direct-Medical Costs Among Persons Aged 3 to 38 Years With and Without Research-Defined Autism Spectrum Disorder Ascertained During Childhood: A Population-Based Birth-Cohort Study

OBJECTIVES

Accurate estimates of autism spectrum disorder (ASD)-associated medical costs are essential for predicting future care needs, allocating resources, identifying best practices, and modeling cost-effectiveness. Most existing studies have either employed subjective cost data or ascertained ASD using self-reported or International Classification of Diseases-coded diagnoses. Such ascertainment is especially problematic for identifying milder ASD among older individuals never diagnosed with ASD.

METHODS

This 1976 through 2000 population-based birth-cohort study was set in Olmsted County, Minnesota. ASD cases and age- and sex-matched unaffected controls were identified by applying uniform operational research criteria for ASD (using the guidelines of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision) after rigorous review of provider-linked medical and public, private, or home school records available for all members from birth to a maximum age of 21 years. Medical cost estimates for the 901 case-control pairs used line-item provider-linked billing data (including all payers) from 2003 through 2014 (ages 3-38 years). Outpatient pharmaceutical costs were unavailable. Temporal changes in diagnostic criteria, clinical practice, public awareness, and access were addressed by separating analyses into 5-year age group and 4-year calendar period cells. Unadjusted and adjusted (age and age plus co-occurring conditions) cost estimates were provided for cases, controls, and case-control differences. Additional factors (co-occurring conditions, percentage hospitalized, intellectual disability) were investigated using unadjusted descriptive analyses.

RESULTS

Cell sample sizes ranged from 93 to 402 for age groups 3 through 19 years and from 45 to 395 for age groups 20 through 38 years. Unadjusted, age-adjusted, and fully adjusted medical costs were significantly higher for cases versus controls in 100% of cells for age groups 3 through 19 years and in 50% (unadjusted), 38% (age adjusted), and 12% (fully adjusted) of cells for age groups 20 through 38 years.

CONCLUSIONS

These unique estimates can help inform the construction of cost-effectiveness models; decisions by payers, providers, and policy makers; and predictions of lifetime costs.

Brief Report: A Job-Based Social Skills Program (JOBSS) for Adults with Autism Spectrum Disorder: A Pilot Randomized Controlled Trial

Adults with autism spectrum disorder (ASD) have low employment rates; even those who are employed have low wages and limited hours. This study evaluated the effectiveness of the Job-Based Social Skills (JOBSS) curriculum, a manualized, 15-week, group-delivered intervention for adults with ASD. The intervention aimed to increase social-pragmatic skills necessary to obtain and maintain employment. Twenty-two adults were randomly assigned to either JOBSS intervention or wait-list control groups. Results showed significant improvement in social cognition, as reported by caregivers, among JOBSS group participants compared to wait-list control participants. Forty-five percent of intervention participants gained employment in the six months following participation. This curriculum has potential to improve social skills of adults with ASD, thereby increasing successful employment.

Clinical and cost effectiveness of staff training in the delivery of Positive Behaviour Support (PBS) for adults with intellectual disabilities, autism spectrum disorder and challenging behaviour - randomised trial

BACKGROUND

Although Positive Behaviour Support (PBS) is a widely used intervention for ameliorating challenging behaviour (CB), evidence for its use in adults with intellectual disability (ID) and comorbid autism (ASD) is lacking. We report a planned subsidiary analysis of adults with both ASD and ID who participated in a randomised trial of PBS delivered by health professionals.

METHODS

The study was a multicentre, cluster randomised trial conducted in 23 community ID services in England, participants were randomly allocated to either the delivery of PBS (n = 11 clusters) or to treatment as usual (TAU; n = 12). One-hundred and thirteen participants (46% of all participants in the trial) had a diagnosis of ID, autism spectrum disorder and CB (ASD+); (47 allocated to the intervention arm, and 66 to the control). CB (primary outcome) was measured with the Aberrant Behaviour Checklist total score (ABC-CT). Secondary outcomes included mental health status, psychotropic medication use, health and social care costs and quality adjusted life years (QALYs) over 12 months.

RESULTS

There were no statistically significant differences in ABC-CT between ASD+ groups randomised to the two arms over 12 months (adjusted mean difference = - 2.10, 95% CI: - 11.3 7.13, p = 0.655) or other measures. The mean incremental cost of the intervention per participant was £628 (95% CI -£1004 to £2013). There was a difference of 0.039 (95% CI - 0.028 to 0.103) for QALYs and a cost per QALY gained of £16,080.

CONCLUSIONS

Results suggest lack of clinical effectiveness for PBS delivered by specialist ID clinical teams. Further evidence is needed from larger trials, and development of improved interventions.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01680276.

ECHO Autism Transition: Enhancing healthcare for adolescents and young adults with autism spectrum disorder

Transition-age youth and young adults with autism spectrum disorder have complex healthcare needs, yet the current healthcare system is not equipped to adequately meet the needs of this growing population. Primary care providers lack training and confidence in caring for youth and young adults with autism spectrum disorder. The current study developed and tested an adaptation of the Extension for Community Healthcare Outcomes model to train and mentor primary care providers (n = 16) in best-practice care for transition-age youth and young adults with autism spectrum disorder. The Extension for Community Healthcare Outcomes Autism Transition program consisted of 12 weekly 1-h sessions connecting primary care providers to an interdisciplinary expert team via multipoint videoconferencing. Sessions included brief didactics, case-based learning, and guided practice. Measures of primary care provider self-efficacy, knowledge, and practice were administered pre- and post-training. Participants demonstrated significant improvements in self-efficacy regarding caring for youth/young adults with autism spectrum disorder and reported high satisfaction and changes in practice as a result of participation. By contrast, no significant improvements in knowledge or perceived barriers were observed. Overall, the results indicate that the model holds promise for improving primary care providers' confidence and interest in working with transition-age youth and young adults with autism spectrum disorder. However, further refinements may be helpful for enhancing scope and impact on practice.

Effectiveness of Parent Education in Pivotal Response Treatment on Pivotal and Collateral Responses

In two studies, we investigated the effectiveness of parent education in Pivotal Response Treatment (PRT) on parent-created opportunities and spontaneous child initiations in two community-based treatment facilities for children with autism spectrum disorder (ASD). Changes in parental stress and self-efficacy were explored. Participants were 26 parents and their children who participated in group (Study 1) or individual (Study 2) parent education in PRT. Results indicated that group-based parent education resulted in moderate increases in opportunities, functional initiations, and empathic social initiations. Furthermore, parental stress reduced and self-efficacy increased. Individual parent education resulted in large increases in opportunities and functional initiations, but parental stress and self-efficacy did not change. Implications for clinical practice and directions for future research are discussed.

Types of Services and Costs of Programs for Preschoolers with Autism Spectrum Disorder Across Sectors: A Comparison of Two Canadian Provinces

This study measured resource utilization and costs for pre-school autism spectrum disorder (ASD)-related services in community-based sectors from multiple payer perspectives in two Canadian provinces, Nova Scotia (NS) and New Brunswick (NB), during the 12 months prior to and following the start of early intensive behavioural intervention (EIBI). The results indicate significant differences between NB and NS in utilization of services and costs to families, public sector and society. Differences can be attributed to variation in EIBI delivery models and may also be influenced by differences in diagnostic assessment practices. The study results provide resource utilization rates and costs which could be used in future economic evaluations and to inform policy making to improve outcomes for children with ASD.

The Economic Costs of Autism Spectrum Disorder: A Literature Review

Autism is associated with a range of costs. This paper reviews the literature on estimating the economic costs of autism spectrum disorder (ASD). More or less 50 papers covering multiple countries (US, UK, Australia, Canada, Sweden, the Netherlands, etc.) were analysed. Six types of costs are discussed in depth: (i) medical and healthcare service costs, (ii) therapeutic costs, (iii) (special) education costs, (iv) costs of production loss for adults with ASD, (v) costs of informal care and lost productivity for family/caregivers, and (vi) costs of accommodation, respite care, and out-of-pocket expenses. A general finding is that individuals with ASD and families with children with ASD have higher costs. Education costs appear to be a major cost component for parents with children with ASD.

Service use, unmet needs, and barriers to services among adolescents and young adults with autism spectrum disorder in Poland

Background

Despite a growing number of adolescents and adults diagnosed with autism spectrum disorder (ASD), little is known about service needs and barriers to services in this population. Existing research shows that youth with ASD are more underserved as they approach final years of their high school education and that adequate services for individuals with ASD after transition to adulthood are even scarcer. However, few studies have directly compared differences in service availability between adolescents and adults with ASD, and even fewer studies are published on service use outside Anglo-Saxon countries. The purpose of the present study was to examine service access, perceived barriers, and unmet needs, as reported by parents of adolescents and young adults with ASD in Poland.

Methods

The study used a subsample of parents of young people with ASD (aged 12–38 years; N = 311) from the Polish Autism Survey – a survey covering different areas of functioning of people with ASD in Poland, based on a convenience sample. Responding parents were recruited via different service providers, social media, and press, and completed a survey using a web platform or a paper-and-pencil questionnaire.

Results

As expected, adults used services less often than adolescents, with 80.1% of adolescents and 61.1% of adults with ASD using services in the previous 12 months. Mental health services were among the most used and the most needed services, followed by educational services, while needs for sensory/motor services remained largely unmet. Young people with a coexisting intellectual disability used more services than those without it. Non-governmental organizations, private clinics, and schools were the most common service providers. Parents indicated that most of young people with ASD had unmet service needs for services (93.5%) and faced barriers to access them (82.7%). Low-income families and those living outside large cities were at the highest risk of facing barriers to service access.

Conclusions

The results confirm still a thin body of evidence from different countries suggesting that adolescents and adults with ASD were both largely underserved populations. Policy-makers should address economic, regional, and age-related inequities in access to services for individuals with ASD.

Cost-Effectiveness of Universal or High-Risk Screening Compared to Surveillance Monitoring in Autism Spectrum Disorder

The American Academy of Pediatrics recommends universal screening for autism spectrum disorder at 18 and 24 months. This study compared the cost-effectiveness of universal or high-risk screening to surveillance monitoring. Simulation models estimated the costs and outcomes from birth to age 6 years. The incremental cost per child diagnosed by 36 months was $41,651.6 for high-risk screening and $757,116.9 for universal screening from the societal perspective. Universal screening may not be a cost-effective approach to increase earlier treatment initiation, as most children initiated treatment after age 60 months. Eliminating wait times resulted in more children initiated treatment by 48 months, but at a high initial cost that may be offset by future cost-savings related to better outcomes.

Brief Report: Service Use and Associated Expenditures Among Adolescents with Autism Spectrum Disorder Transitioning to Adulthood

This study compared Medicaid service utilization and expenditures among adolescents with autism spectrum disorder (ASD) to adolescents with intellectual disability (ID) as they aged into adulthood. Medicaid Analytic eXtract (MAX) data was used to identify a national cohort. Winsorization was utilized to control for expenditure outliers. A greater proportion of adolescents with ASD utilized most services. Decreases in the use of key services, including psychiatric outpatient services, were observed for both groups. Changes in medical services, such as increases in inpatient and long term care services, among the ASD cohort suggest medical needs of adolescents with ASD change as they age. Information remains lacking on changing ASD symptom presentation during the transition to adolescence.

Focus on the Social Aspect of Autism

Autism spectrum disorder (ASD) describes a set of neurodevelopmental disorders. Despite extensive ASD research lasting more than 60 years, its causes are still unknown. Without indicating the etiology, its development cannot be stopped. Over the years, both the definition and diagnostic criteria have developed. The number of ASD incidence is rising. The economical aspect should also be highlighted. This disorder presents particular challenges to affected children, their parents and physicians. The research of ASD, physician activities, policy making and raising the level of awareness must be coordinated. Special attention should be paid to the problem among adults with ASD.

Use, costs, and predictors of psychiatric healthcare services following an autism spectrum diagnosis: Population-based cohort study

A number of cross-sectional studies report extensive use of psychiatric services and high healthcare costs in autistic youths. However, little is known about how the use of these services evolves from the time of diagnosis, as children grow up. Our objectives were to investigate the use, costs, and predictors of psychiatric services following autism spectrum diagnosis. We built a cohort of 1227 newly diagnosed autism spectrum individuals identified in the Quebec (Canada) Régie de l'assurance maladie du Québec administrative database (January 1998 to December 2010). Mean number and cost per individual of psychiatric healthcare use (hospitalizations, medical visits, psychoactive drug use) were calculated yearly for 5 years following autism spectrum diagnosis. Mean number of psychiatric visits decreased over time by more than threefold (7.5 vs 2.1 visits) from year 1 to year 5, whereas psychoactive drug use increased from 16.0 to 25.2 claims. Psychiatric hospitalizations decreased during follow-up, but still represented the greatest costs per individual (CAD9820 for year 1; CAD4628 for year 5). Antipsychotics represented over 50% of drug costs. Mixed-effect model with repeated measures showed that previous psychoactive drug use was the strongest predictor of greater psychiatric healthcare cost during follow-up (odds ratio: 9.96; 95% confidence interval: 7.58-13.10). These trends contrast with guidelines advocating cautious prescribing of antipsychotics with periodical re-assessment of their benefit.

Health Care Service Utilization and Cost Among Adults with Autism Spectrum Disorders in a U.S. Integrated Health Care System

Objectives

To compare health care utilization patterns and cost among insured adults with autism spectrum disorder (ASD), adults with attention-deficit and hyperactivity disorder (ADHD), and adults with neither condition (general population [GP] controls).

Method

We conducted a case-control study among adults (≥18 years) who were members of Kaiser Permanente Northern California (KPNC) for at least 9 months each year from 2008 to 2012. Cases (N = 1507) were adults with an ASD diagnosis (ICD-9-CM 299.0-299.8) recorded in the electronic medical record on at least two separate occasions by December 31, 2012. Two control groups, adults with ADHD (N = 9042) defined by ICD-9-CM code 314 and GP (N = 15,070), were randomly selected and frequency matched to cases on gender and age. Health care utilization and cost data were obtained from KPNC databases for the year 2012.

Results

Compared with adults with ADHD, adults with ASD had significantly higher utilization of outpatient visits for primary care (74.2% vs. 66.6%), mental health (43.3% vs. 33.2%), and laboratory services (60.9% vs. 54.4%). Hospitalizations for ambulatory care sensitive diagnoses (5.4% vs. 2.3%) were less frequent overall but more common among adults with ASD than with ADHD. Group differences were larger comparing adults with ASD with GP controls. Gynecology visits and screening for cervical cancer were significantly less common among women with ASD than among women with ADHD (35% vs. 50%) or GP (35% vs. 49%). Total annual mean healthcare costs for adults with ASD were 20% higher than costs for adults with ADHD and double costs for GP.

Conclusion

Adults with ASD had significantly higher rates of utilization across most health care service areas compared with adults with ADHD or GP; however, women with ASD were significantly less likely to have gynecology visits and have screening for cervical cancer.

Lay Summary

We conducted a study among adults (≥18 years) who were members of Kaiser Permanente Northern California (KPNC) from 2008 to 2012. We compared how often people attended different types of health care and costs of health care among adults with autism spectrum disorder (ASD), adults with attention-deficit and hyperactivity disorder (ADHD), and adults with neither condition (general population [GP] controls). The study included 1507 adults with ASD, 9042 with ADHD but not ASD, and 15,070 GP controls with no ASD or ADHD. Health care and cost data were obtained from KPNC databases for the year 2012. The study found that adults with ASD used more outpatient visits for primary care, mental health, and laboratory services than adults with ADHD. Gynecology visits and screening for cervical cancer were less common among women with ASD than among women with ADHD or GP. Health care costs for adults with ASD were higher than costs for adults with ADHD and costs for GP. In conclusion, adults with ASD had higher rates of use of most health care service areas than adults with ADHD or GP; however, women with ASD were less likely to have gynecology visits and have screening for cervical cancer.

Brief Report: Regional Variations in Characteristics of ASD Hospitalizations in the U.S

Regional differences in ASD inpatient care remain understudied. We used the Nationwide Inpatient Sample to examine contributory causes and potential determinants associated with regional variations in ASD hospitalizations. We performed univariate and multivariate analyses to identify differences in ASD hospitalizations across four U.S. Census Bureau-defined regions. Our results revealed considerable variations in ASD hospitalizations across U.S. regions. Compared with patients in the Northeast, those in the Midwest, South, and West were less likely to be hospitalized for ASD. Significant differences were observed among regions with regard to the effect of health insurance type, hospital length of stay, hospital bed size, hospital location and teaching status on ASD hospitalizations. The region-specific analysis provides direction for further investigation.

Effects Of State Insurance Mandates On Health Care Use And Spending For Autism Spectrum Disorder

Forty-six states and the District of Columbia have enacted insurance mandates that require commercial insurers to cover treatment for children with autism spectrum disorder (ASD). This study examined whether implementing autism mandates altered service use or spending among commercially insured children with ASD. We compared children age twenty-one or younger who were eligible for mandates to children not subject to mandates using 2008-12 claims data from three national insurers. Increases in service use and spending attributable to state mandates were detected for all outcomes. Mandates were associated with a 3.4-percentage-point increase in monthly use and a $77 increase in monthly spending on ASD-specific services. Effects were larger for younger children and increased with the number of years since mandate implementation. These increases suggest that state mandates are an effective tool for broadening access to autism treatment under commercial insurance.

How to apply SHA 2011 at a subnational level in China's practical situation: take children health expenditure as an example

Background

System of Health Accounts 2011 (SHA 2011) is a new health care accounts system, revised from SHA 1.0 by the Organisation for Economic Co-operation and Development (OECD), the World Health Organization (WHO) and Eurostat. It keeps the former tri-axial relationship and develops three analytical interfaces, in order to fix the existing shortcomings and make it more convenient for analysis and comparison across countries. SHA 2011 was introduced in China in 2014, and little about its application in China has been reported. This study takes children as an example to study how to apply SHA 2011 at the subnational level in the practical situation of China’s health system.

Methods

Multistage random sampling method was applied and 3 532 517 samples from 252 institutions were included in the study. Official yearbooks and account reports helped the estimation of provincial data. The formula to calculate Current Health Expenditure (CHE) was introduced step-by-step. STATA 10.0 was used for statistics.

Results

Under the frame of SHA 2011, the CHE for children in Liaoning was calculated as US$ 0.74 billion in 2014; 98.56% of the expenditure was spent in hospital and the allocation to primary health care institutions was insufficient. Infection, maternal and prenatal diseases cost the most in terms of Global Burden of Disease (GBD), and respiratory system diseases took the leading place in terms of International Classification of Disease Tenth Revision (ICD-10). In addition, medical income contributed most to the health financing.

Conclusions

The method to apply SHA 2011 at the subnational level is feasible in China. It makes health accounts more adaptable to rapidly developing health systems and makes the financing data more readily available for analytical use. SHA 2011 is a better health expenditure accounts system to reveal the actual burden on residents and deserves further promotion in China as well as around the world.

Parent-reported early symptoms of autism spectrum disorder in children without intellectual disability who were diagnosed at school age

Despite efforts to detect autism spectrum disorder during toddlerhood, many children with autism spectrum disorder remain undiagnosed until school age. To identify characteristics of children whose autism spectrum disorder might not be diagnosed during toddlerhood, this study used archived Autism Diagnostic Interview-Revised records to examine the historical presentation of autism spectrum disorder symptoms in 48 school-age children with autism spectrum disorder. Children diagnosed after starting school (Late-Diagnosed; n = 24) were compared to age-matched children diagnosed before school age (Early-Diagnosed; n = 24). Symptom presentation was similar between groups, with the Late-Diagnosed group exhibiting only marginally fewer symptoms historically. The most commonly reported historical symptoms were negative symptoms, namely, deficits in social behaviors. Positive symptoms, such as unusual preoccupations, rituals, and mannerisms, were less commonly reported. These findings may aid earlier identification of autism spectrum disorder in children who would likely be diagnosed at school age.

Parent and Teacher Concordance of Child Outcomes for Youth with Autism Spectrum Disorder

Cross-informant ratings of are considered gold standard for child behavioral assessment. To date, little work has examined informant ratings of adaptive functioning for youth with autism spectrum disorder (ASD). In a large, diverse sample of youth with ASD, this study evaluated parent-teacher concordance of ratings of adaptive functioning and ASD-specific symptomatology across time. The impact of child clinical characteristics on concordance was also examined. Participants included 246 children, their caregivers and teachers. Parent-teacher concordance was variable but generally consistent across time. Concordance was significantly impacted by autism severity and child cognitive abilities. Findings inform the broader concordance literature and support the need to consider child clinical factors when assessing child functioning in samples of children with ASD.