Effects of Geography on Risk for Future Suicidal Ideation and Attempts Among Children and Youth

Objective

Geography may influence the relationships of predictors for suicidal ideation (SI) and suicide attempts (SA) in children and youth.

Method

This is a nationwide retrospective cohort study of 124,424 individuals less than 25 years of age using commercial claims data (2011-2015) from the Health Care Cost Institute. Outcomes were time to SI or SA within 3 months after the indexed mental health or substance use disorder (MH/SUD) outpatient visit. Predictors included sociodemographic and clinical characteristics up to 3 years before the index event.

Results

At each follow-up time period, rates of SI and SA varied by the US geographic division (p < .001), and the Mountain Division consistently had the highest rates for both SI and SA (5.44%-10.26% for SI; 0.70%-2.82% for SA). Having MH emergency department (ED) visits in the past year increased the risk of SI by 28% to 65% for individuals residing in the New England, Mid-Atlantic, East North Central, West North Central, and East South Central Divisions. The main effects of geographic divisions were significant for SA (p<0.001). Risk of SA was lower in New England, Mid-Atlantic, South Atlantic, and Pacific (hazard ratios = 0.57, 0.51, 0.67, and 0.79, respectively) and higher in the Mountain Division (hazard ratio = 1.46).

Conclusion

To understand the underlying mechanisms driving the high prevalence of SI and SA in the Mountain Division and the elevated risk of SI after having MH ED visits, future research examining regional differences in risks for SI and SA should include indicators of access to MH ED care and other social determinants of health.

Medications for Alcohol Use Disorder and Retention in Care in Medicaid-Enrolled Youth, 2014-2019

PURPOSE

Alcohol use disorder (AUD) is a pediatric-onset condition needing timely, effective treatment. Medications for AUD are part of nationally recommended treatments for youth. This study measured receipt of medications and behavioral health services for AUD and subsequent retention in care.

METHODS

This retrospective cohort study used claims data from > 4.7 million publicly insured youth aged 13-22 years in 15 states from 2014-2019. Timely treatment was defined as receipt of medication (naltrexone, acamprosate, or disulfiram) and/or behavioral health services within 30 days of incident AUD diagnosis. Associations of age and other characteristics with timely treatment were identified using modified Poisson regression. Retention in care (i.e., no period ≥ 60 days without claims) was studied using Cox regression.

RESULTS

Among 14,194 youth with AUD, 10,851 (76.4%) received timely treatment. Only 2.1% of youth received medication (alone or in combination); nearly all (97.9%) received behavioral health services only. Older (aged 16-17 years) and younger adolescents (aged 13-15 years) were 0.13 (95% confidence interval [CI], 0.07-0.26) and 0.24 (95% CI, 0.11-0.51) times as likely, respectively, to receive medications than young adults aged ≥ 21 years. Median retention in care for youth receiving medications was 119 days (interquartile range, 54-321) compared with 108 days (interquartile range, 43-243) for behavioral health services alone (p = .126). Young adults aged ≥ 18 years were 1.12 (95% CI, 1.06-1.18) times as likely to discontinue treatment compared with adolescents aged < 18 years.

DISCUSSION

This study found that more than seven in 10 youth received AUD treatment but only two in 100 received medications. Future studies should further characterize the effectiveness of medications and determine whether low rates of receipt represent underuse.

Editorial: Global Widening of the Inequitable Child and Adolescent Mental Health Care Chasm During COVID-19

The long-standing and inequitable chasm between clinical need and child and adolescent mental health care has likely widened during the COVID-19 pandemic, especially for children and adolescents in developing low- and middle-income countries (LMICs). Internationally, the risk for suicidal behaviors among young people rose, while timely access to care worsened.1 People in LMICs are envisioned to be precariously positioned within a perfect storm characterized by greater exposure to life-threatening COVID-19-related social determinants of health that also pose higher risk of new and recurrent mental disorders.2 In this issue of the Journal, the study by Wong et al.3 is the first international study to report a substantial rise in emergency department (ED) visits for any psychiatric disorder and self-harm among children and adolescents after the onset of the COVID-19 pandemic. Using a retrospective cohort study design, ED visits for any psychiatric disorder and self-harm were compared between March-April of 2019 (prepandemic), 2020 (early pandemic), and 2021 (later pandemic), with the most recent time interval corresponding to the "third wave of the pandemic worldwide." The total sample included 8,174 psychiatric ED visits to 62 emergency units in 25 countries, including developing countries with lower-middle, upper-middle, and high incomes as well as developed countries with upper-middle and high incomes. Of these, 3,865 psychiatric ED visits in 13 countries had data for all time intervals. Using the complete data, compared with March-April 2019, the rate of ED visits for any psychiatric disorder was lower in March-April 2020, consistent with the abrupt drop reported in the United States that broadly aligns with statewide school closures and shelter in place orders.4,5 However, when comparing early pandemic with later pandemic time intervals matched by months, the rates for any psychiatric and self-harm ED visits were twice as high. Despite the sharp drop following the onset of the pandemic, when compared with the prepandemic time interval, the overall rates of ED visits for any psychiatric diagnosis and self-harm during the later pandemic were 50% and 70% higher, respectively. Girls were also at greater risk for self-harm ED visits following the onset of the COVID-19 pandemic. Compared with the prepandemic time interval matched by months, girls had almost twice the odds of a self-harm ED visit in March-April 2021. The international rise in self-harm ED visits likely driven by the increases among girls is also consistent with prior US studies.4,5.

Availability of LGBTQ Mental Health Services for US Youth, 2014 to 2020

This survey study reports the variability of lesbian, gay, bisexual, transgender, queer (LGBTQ) youth–specific mental health care in the US from 2014 to 2020.

Assessing Detection of Children With Suicide-Related Emergencies: Evaluation and Development of Computable Phenotyping Approaches

BACKGROUND

Although suicide is a leading cause of death among children, the optimal approach for using health care data sets to detect suicide-related emergencies among children is not known.

OBJECTIVE

This study aimed to assess the performance of suicide-related International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and suicide-related chief complaint in detecting self-injurious thoughts and behaviors (SITB) among children compared with clinician chart review. The study also aimed to examine variations in performance by child sociodemographics and type of self-injury, as well as develop machine learning models trained on codified health record data (features) and clinician chart review (gold standard) and test model detection performance.

METHODS

A gold standard classification of suicide-related emergencies was determined through clinician manual review of clinical notes from 600 emergency department visits between 2015 and 2019 by children aged 10 to 17 years. Visits classified with nonfatal suicide attempt or intentional self-harm using the Centers for Disease Control and Prevention surveillance case definition list of ICD-10-CM codes and suicide-related chief complaint were compared with the gold standard classification. Machine learning classifiers (least absolute shrinkage and selection operator-penalized logistic regression and random forest) were then trained and tested using codified health record data (eg, child sociodemographics, medications, disposition, and laboratory testing) and the gold standard classification. The accuracy, sensitivity, and specificity of each detection approach and relative importance of features were examined.

RESULTS

SITB accounted for 47.3% (284/600) of the visits. Suicide-related diagnostic codes missed nearly one-third (82/284, 28.9%) and suicide-related chief complaints missed more than half (153/284, 53.9%) of the children presenting to emergency departments with SITB. Sensitivity was significantly lower for male children than for female children (0.69, 95% CI 0.61-0.77 vs 0.84, 95% CI 0.78-0.90, respectively) and for preteens compared with adolescents (0.66, 95% CI 0.54-0.78 vs 0.86, 95% CI 0.80-0.92, respectively). Specificity was significantly lower for detecting preparatory acts (0.68, 95% CI 0.64-0.72) and attempts (0.67, 95% CI 0.63-0.71) than for detecting ideation (0.79, 95% CI 0.75-0.82). Machine learning-based models significantly improved the sensitivity of detection compared with suicide-related codes and chief complaint alone. Models considering all 84 features performed similarly to models considering only mental health-related ICD-10-CM codes and chief complaints (34 features) and models considering non-ICD-10-CM code indicators and mental health-related chief complaints (53 features).

CONCLUSIONS

The capacity to detect children with SITB may be strengthened by applying a machine learning-based approach to codified health record data. To improve integration between clinical research informatics and child mental health care, future research is needed to evaluate the potential benefits of implementing detection approaches at the point of care and identifying precise targets for suicide prevention interventions in children.

Timing of Mental Health Service Use After a Pediatric Firearm Injury

OBJECTIVES

To examine how timing of the first outpatient mental health (MH) visit after a pediatric firearm injury varies by sociodemographic and clinical characteristics.

METHODS

We retrospectively studied children aged 5 to 17 years with a nonfatal firearm injury from 2010 to 2018 using the IBM Watson MarketScan Medicaid database. Logistic regression estimated the odds of MH service use in the 6 months after injury, adjusted for sociodemographic and clinical characteristics. Cox proportional hazard models, stratified by previous MH service use, evaluated variation in timing of the first outpatient MH visit by sociodemographic and clinical characteristics.

RESULTS

After a firearm injury, 958 of 2613 (36.7%) children used MH services within 6 months; of these, 378 of 958 (39.5%) had no previous MH service use. The adjusted odds of MH service use after injury were higher among children with previous MH service use (adjusted odds ratio, 10.41; 95% confidence interval [CI], 8.45-12.82) and among non-Hispanic white compared with non-Hispanic Black children (adjusted odds ratio, 1.29; 95% CI, 1.02-1.63). The first outpatient MH visit after injury occurred sooner among children with previous MH service use (adjusted hazard ratio, 6.32; 95% CI, 5.45-7.32). For children without previous MH service use, the first MH outpatient visit occurred sooner among children with an MH diagnosis made during the injury encounter (adjusted hazard ratio, 2.72; 95% CI, 2.04-3.65).

CONCLUSIONS

More than 3 in 5 children do not receive MH services after firearm injury. Previous engagement with MH services and new detection of MH diagnoses during firearm injury encounters may facilitate timelier connection to MH services after injury.

Follow-up After Pediatric Mental Health Emergency Visits

OBJECTIVES

To examine how outpatient mental health (MH) follow-up after a pediatric MH emergency department (ED) discharge varies by patient characteristics and to evaluate the association between timely follow-up and return encounters.

METHODS

We conducted a retrospective study of 28 551 children aged 6 to 17 years with MH ED discharges from January 2018 to June 2019, using the IBM Watson MarketScan Medicaid database. Odds of nonemergent outpatient follow-up, adjusted for sociodemographic and clinical characteristics, were estimated using logistic regression. Cox proportional hazard models were used to evaluate the association between timely follow-up and risk of return MH acute care encounters (ED visits and hospitalizations).

RESULTS

Following MH ED discharge, 31.2% and 55.8% of children had an outpatient MH visit within 7 and 30 days, respectively. The return rate was 26.5% within 6 months. Compared with children with no past-year outpatient MH visits, those with ≥14 past-year MH visits had 9.53 odds of accessing follow-up care within 30 days (95% confidence interval [CI], 8.75-10.38). Timely follow-up within 30 days was associated with a 26% decreased risk of return within 5 days of the index ED discharge (hazard ratio, 0.74; 95% CI, 0.63-0.91), followed by an increased risk of return thereafter.

CONCLUSIONS

Connection to outpatient care within 7 and 30 days of a MH ED discharge remains poor, and children without prior MH outpatient care are at highest risk for poor access to care. Interventions to link to outpatient MH care should prioritize follow-up within 5 days of an MH ED discharge.

Use of Acute Mental Health Care in U.S. Children's Hospitals Before and After Statewide COVID-19 School Closure Orders

OBJECTIVE

This study aimed to examine changes in child emergency department (ED) discharges and hospitalizations for primary general medical (GM) and primary psychiatric disorders; prevalence of psychiatric disorders among acute care encounters; and change in acute mental health (MH) care encounters by disorder type and, within these categories, by child sociodemographic characteristics before and after statewide COVID-19–related school closure orders.

METHODS

This retrospective, cross-sectional cohort study used the Pediatric Health Information System database to assess percent changes in ED discharges and hospitalizations (N=2,658,474 total encounters) among children ages 3–17 years in 44 U.S. children’s hospitals in 2020 compared with 2019, by using matched data for 36- and 12-calendar-week intervals.

RESULTS

Decline in MH ED discharges accounted for about half of the decline in ED discharges and hospitalizations for primary GM disorders (−24.8% vs. −49.1%), and MH hospitalizations declined 3.4 times less (−8.0% vs. −26.8%) in 2020. Suicide attempt or self-injury and depressive disorders accounted for &gt;50% of acute MH care encounters before and after the statewide school closures. The increase in both ED discharges and hospitalizations for suicide attempt or self-injury was 5.1 percentage points (p&lt;0.001). By fall 2020, MH hospitalizations for suicide attempt or self-injury rose by 41.7%, with a 43.8% and 49.2% rise among adolescents and girls, respectively.

CONCLUSIONS

Suicide or self-injury and depressive disorders drove acute MH care encounters in 44 U.S. children’s hospitals after COVID-19–related school closures. Research is needed to identify continuing risk indicators (e.g., sociodemographic characteristics, psychiatric disorder types, and social determinants of health) of acute child MH care.

Mental Health Care Following Firearm and Motor Vehicle-related Injuries: Differences Impacting Our Treatment Strategies

OBJECTIVE

To compare new mental health diagnoses (NMHD) in children after a firearm injury versus following a motor vehicle collision (MVC).

BACKGROUND

A knowledge gap exists regarding childhood mental health diagnoses following firearm injuries, notably in comparison to other forms of traumatic injury.

METHODS

We utilized Medicaid MarketScan claims (2010-2016) to conduct a matched case-control study of children ages 3 to 17 years. Children with firearm injuries were matched with up to 3 children with MVC injuries. Severity was determined by injury severity score and emergency department disposition. We used multivariable logistic regression to measure the association of acquiring a NMHD diagnosis in the year postinjury after firearm and MVC mechanisms.

RESULTS

We matched 1450 children with firearm injuries to 3691 children with MVC injuries. Compared to MVC injuries, children with firearm injuries were more likely to be black, have higher injury severity score, and receive hospital admission from the emergency department ( P <0.001). The adjusted odds ratio (aOR) of NMHD diagnosis was 1.55 [95% confidence interval (95% CI): 1.33-1.80] greater after firearm injuries compared to MVC injuries. The odds of a NMHD were higher among children admitted to the hospital compared to those discharged. The increased odds of NMHD after firearm injuries was driven by increases in substance-related and addictive disorders (aOR: 2.08; 95% CI: 1.63-2.64) and trauma and stressor-related disorders (aOR: 2.07; 95% CI: 1.55-2.76).

CONCLUSIONS

Children were found to have 50% increased odds of having a NMHD in the year following a firearm injury as compared to MVC. Programmatic interventions are needed to address children's mental health following firearm injuries.

Mental Health-Related Emergency Department Visits Among Children During The Early COVID-19 Pandemic

Objective

To measure univariate and covariate-adjusted trends in children's mental health-related emergency department (MH-ED) use across geographically diverse areas of the U.S. during the first wave of the Coronavirus-2019 (COVID-19) pandemic.

Method

This is a retrospective, cross-sectional cohort study using electronic health records from four academic health systems, comparing percent volume change and adjusted risk of child MH-ED visits among children aged 3-17 years, matched on 36-week (3/18/19-11/25/19 vs. 3/16/20-11/22/20) and 12-week seasonal time intervals. Adjusted incidence rate ratios (IRR) were calculated using multivariate Poisson regression.

Results

Visits declined during spring-fall 2020 (n = 3892 vs. n = 5228, -25.5%) and during spring (n = 1051 vs. n = 1839, -42.8%), summer (n = 1430 vs. n = 1469, -2.6%), and fall (n = 1411 vs. n = 1920, -26.5%), compared with 2019. There were greater declines among males (28.2% vs. females -22.9%), children 6-12-year (-28.6% vs. -25.9% for 3-5 years and -22.9% for 13-17 years), and Black children (-34.8% vs. -17.7% to -24.9%). Visits also declined for developmental disorders (-17.0%) and childhood-onset disorders (e.g., attention deficit and hyperactivity disorders; -18.0%). During summer-fall 2020, suicide-related visits rose (summer +29.8%, fall +20.4%), but were not significantly elevated from 2019 when controlling for demographic shifts. In contrast, MH-ED use during spring-fall 2020 was significantly reduced for intellectual disabilities (IRR 0.62 [95% CI 0.47-0.86]), developmental disorders (IRR 0.71 [0.54-0.92]), and childhood-onset disorders (IRR 0.74 [0.56-0.97]).

Conclusions

The early pandemic brought overall declines in child MH-ED use alongside co-occurring demographic and diagnostic shifts. Children vulnerable to missed detection during instructional disruptions experienced disproportionate declines, suggesting need for future longitudinal research in this population.

Prolonged Emergency Department Length of Stay for US Pediatric Mental Health Visits (2005-2015)

BACKGROUND AND OBJECTIVES

Children seeking care in the emergency department (ED) for mental health conditions are at risk for prolonged length of stay (LOS). A more contemporary description of trends and visit characteristics associated with prolonged ED LOS at the national level is lacking in the literature. Our objectives were to (1) compare LOS trends for pediatric mental health versus non-mental health ED visits and (2) explore patient-level characteristics associated with prolonged LOS for mental health ED visits.

METHODS

We conducted an observational analysis of ED visits among children 6 to 17 years of age using the National Hospital Ambulatory Medical Care Survey (2005-2015). We assessed trends in rates of prolonged LOS and the association between prolonged LOS and demographic and clinical characteristics (race and ethnicity, payer type, and presence of a concurrent physical health diagnosis) using descriptive statistics and survey-weighted logistic regression.

RESULTS

From 2005 to 2015, rates of prolonged LOS for pediatric mental health ED visits increased over time from 16.3% to 24.6% (LOS >6 hours) and 5.3% to 12.7% (LOS >12 hours), in contrast to non-mental health visits for which LOS remained stable. For mental health visits, Hispanic ethnicity was associated with an almost threefold odds of LOS >12 hours (odds ratio 2.74; 95% confidence interval 1.69-4.44); there was no difference in LOS by payer type.

CONCLUSIONS

The substantial rise in prolonged LOS for mental health ED visits and disparity for Hispanic children suggest worsening and inequitable access to definitive pediatric mental health care. Policy makers and health systems should work to provide equitable and timely access to pediatric mental health care.

Editors' Note and Special Communication: Research Priorities in Child and Adolescent Mental Health Emerging From the COVID-19 Pandemic

Over the last year, the coronavirus disease 2019 (COVID-19) pandemic has resulted in profound disruptions across the globe, with school closures, social isolation, job loss, illness, and death affecting the lives of children and families in myriad ways. In an Editors' Note in our June 2020 issue,¹ our senior editorial team described this Journal's role in advancing knowledge in child and adolescent mental health during the pandemic and outlined areas we identified as important for science and practice in our field. Since then, the Journal has published articles on the impacts of the pandemic on child and adolescent mental health and service systems,^2-5 which are available in a special collection accessible through the Journal's website.⁶ Alongside many opinion papers, the pace of publication of empirical research in this area is rapidly expanding, covering important issues such as increased frequency of mental health symptoms among children and adolescents^3,5,7-10 and changes in patterns of clinical service use such as emergency department visits.^11-14 As the Senior Editors prepared that Editors' Note, they were acutely aware that the priorities that they identified were broad and generated by only a small group of scientists and clinicians. Although this had the advantage of enabling us to get this information out to readers quickly, we decided that a more systematic approach to developing recommendations for research priorities would be of greater long-term value. We were particularly influenced by the efforts of the partnership between the UK Academy of Medical Scientists and a UK mental health research charity (MQ: Transforming Mental Health) to detail COVID-19-related research priorities for "Mental Health Science" that was published online by Holmes et al. in The Lancet Psychiatry in April 2020.¹⁵ Consistent with its focus on mental health research across the lifespan, several recommendations highlighted child development and children's mental health. However, a more detailed assessment of research priorities related to child and adolescent mental health was beyond the scope of that paper. Furthermore, the publication of that position paper preceded the death of George Floyd at the hands of Minneapolis police on May 25, 2020, which re-energized efforts to acknowledge and to address racism and healthcare disparities in the United States and many other countries. To build upon the JAACAP Editors' Note¹ and the work of Holmes et al.,¹⁵ we conducted an international survey of professionals-practitioners and researchers-working on child and adolescent development and pediatric mental health to identify concerns about the impact of the pandemic on children, adolescents, and their families, as well as what is helping families navigate these impacts, and the specific research topics that are of greatest importance.

Editorial: The Cost of Comorbid Child Psychiatric Disorders: A National Call to Achieve the Triple Aim for Child Mental Health Care

The National Quality Strategy to transform the US health care system is predicated upon Donald Berwick et al.'s "Triple Aim" envisioning the simultaneous pursuit of improved care, better population health, and reduced costs.¹ More recently, emphasis has been placed on improving the value of health care as defined by "achieving the best patient health outcomes (quality + experience) at the lowest cost."² US health care expenditures are projected to grow at an average annual rate of 5.4% during this decade, reaching 19.7% of the gross domestic product or an estimated 6.1 billion dollars by 2028.³ Compared with 36 high-income countries, including Canada, the US spends nearly twice as much on health care yet has the lowest life expectancy and highest suicide rate.⁴ However, solely targeting reduction in mental health care costs is not a solution, because the mental and general health care systems are inextricably linked⁵ and for children span multiple care sectors (eg, schools, child welfare, juvenile justice). In this issue of the Journal, Ansari et al.⁶ validates the complexity of physically ill children with a comorbid psychiatric disorder among more than 50,000 admissions to an acute-care pediatric specialty hospital within Canada's publicly funded health care system. Almost one out of 10 admissions for a physical illness had a documented comorbid psychiatric disorder, which is consistent with US pediatric hospital discharges.⁷ Children who were older, more clinically complex, and with prior hospitalizations were more likely to be among inpatient admissions with a comorbid psychiatric disorder. With outstanding methodologic rigor, the data suggest that pediatric inpatient admissions with comorbid psychiatric disorders had a nearly 10% longer length of stay and higher costs per admission compared with inpatient admissions without a comorbid psychiatric disorder---a difference in total cumulative costs of more than CAN$11.3 million (equivalent of about US$8.4 million).

Measurement-based Data to Monitor Quality: Why Specification at the Population Level Matter?

Measurement-based care is conceptualized as a driver for quality improvement. The triple aim in the National Quality Strategy purposively muddles the population levels to provide a health policy goal that is encompassing, transactional, and will stimulate change. Specification of the population level has implications for the purpose, proposed target mechanisms that drive quality improvement, methodologic challenges, and implications for program evaluation and data interpretation. To demonstrate, population levels are conceptualized at the individual (tier 1), clinical aggregate (tier 2), and national level (tier 3).

Health Care Utilization and Spending for Children With Mental Health Conditions in Medicaid

OBJECTIVE

To examine how characteristics vary between children with any mental health (MH) diagnosis who have typical spending and the highest spending; to identify independent predictors of highest spending; and to examine drivers of spending groups.

METHODS

This retrospective analysis utilized 2016 Medicaid claims from 11 states and included 775,945 children ages 3 to 17 years with any MH diagnosis and at least 11 months of continuous coverage. We compared demographic characteristics and Medicaid expenditures based on total health care spending: the top 1% (highest-spending) and remaining 99% (typical-spending). We used chi-squared tests to compare the 2 groups and adjusted logistic regression to identify independent predictors of being in the top 1% highest-spending group.

RESULTS

Children with MH conditions accounted for 55% of Medicaid spending among 3- to 17-year olds. Patients in the highest-spending group were more likely to be older, have multiple MH conditions, and have complex chronic physical health conditions (P <.001). The highest-spending group had $164,003 per-member-per-year (PMPY) in total health care spending, compared to $6097 PMPY in the typical-spending group. Ambulatory MH services contributed the largest proportion (40%) of expenditures ($2455 PMPY) in the typical-spending group; general health hospitalizations contributed the largest proportion (36%) of expenditures ($58,363 PMPY) in the highest-spending group.

CONCLUSIONS

Among children with MH conditions, mental and physical health comorbidities were common and spending for general health care outpaced spending for MH care. Future research and quality initiatives should focus on integrating MH and physical health care services and investigate whether current spending on MH services supports high-quality MH care.

ED Visits and Readmissions After Follow-up for Mental Health Hospitalization

OBJECTIVES

A national quality measure in the Child Core Set is used to assess whether pediatric patients hospitalized for a mental illness receive timely follow-up care. In this study, we examine the relationship between adherence to the quality measure and repeat use of the emergency department (ED) or repeat hospitalization for a primary mental health condition.

METHODS

We used the Truven MarketScan Medicaid Database 2015-2016, identifying hospitalizations with a primary diagnosis of depression, bipolar disorder, psychosis, or anxiety for patients aged 6 to 17 years. Primary predictors were outpatient follow-up visits within 7 and 30 days. The primary outcome was time to subsequent mental health-related ED visit or hospitalization. We conducted bivariate and multivariate analyses using Cox proportional hazard models to assess relationships between predictors and outcome.

RESULTS

Of 22 844 hospitalizations, 62.0% had 7-day follow-up, and 82.3% had 30-day follow-up. Subsequent acute use was common, with 22.4% having an ED or hospital admission within 30 days and 54.8% within 6 months. Decreased likelihood of follow-up was associated with non-Hispanic or non-Latino black race and/or ethnicity, fee-for-service insurance, having no comorbidities, discharge from a medical or surgical unit, and suicide attempt. Timely outpatient follow-up was associated with increased subsequent acute care use (hazard ratio [95% confidence interval]: 7 days: 1.20 [1.16-1.25]; 30 days: 1.31 [1.25-1.37]). These associations remained after adjusting for severity indicators.

CONCLUSIONS

Although more than half of patients received follow-up within 7 days, variations across patient population suggest that care improvements are needed. The increased hazard of subsequent use indicates the complexity of treating these patients and points to potential opportunities to intervene at follow-up visits.

Measures of ED utilization in a national cohort of children

OBJECTIVES

Emergency department (ED) utilization is often used as an indicator of poor chronic disease control and/or poor quality of care. We sought to determine if 2 ED utilization measures identify clinically or demographically different populations of children.

STUDY DESIGN

Retrospective cohort study utilizing IBM Health/Truven MarketScan Medicaid data.

METHODS

Children and adolescents were categorized based on the presence and complexity of chronic medical conditions using the 3M Clinical Risk Group system. Children and adolescents were categorized as high ED utilizers using 2 measures: (1) ED reliance (EDR) (number of ED visits / [number of ED visits + number of ambulatory visits]; EDR >0.33 = high utilizer) and (2) visit counts (≥3 ED visits = high utilizer). Logistic regression models identified patient factors associated with each of our outcome measures.

RESULTS

A total of 5,438,541 children and adolescents were included; 65% were without chronic disease (WO-CD), 32% had noncomplex chronic disease (NC-CD), and 3% had complex chronic disease (C-CD). EDR identified 18% as frequent utilizers compared with 7% by the visit count measure. In the visit count model, children younger than 2 years and those classified as WO-CD and NC-CD were less likely to be identified as high utilizers. Conversely, in the EDR model, children and adolescents 2 years and older and those classified as WO-CD and NC-CD were more likely to be classified as high utilizers.

CONCLUSIONS

The ED utilization measures identify clinically and demographically different groups of patients. Future studies should consider the medical complexity of the population being studied before choosing the most appropriate measure to employ.

The Impact of Attachment-Disrupting Adverse Childhood Experiences on Child Behavioral Health

OBJECTIVES

To describe patterns of overall, within-household, and community adverse childhood experiences (ACEs) among children in vulnerable neighborhoods and to identify which individual ACEs, over and above overall ACE level, predict need for behavioral health services.

STUDY DESIGN

This was a cross-sectional study that used a sample of 257 children ages 3-16 years who were seeking primary care services with co-located mental healthcare services at 1 of 2 clinics in Chicago, Illinois. The outcome variable was need for behavioral health services (Pediatric Symptom Checklist score ≥28). The independent variables were ACEs, measured with an adapted, 28-item version of the Traumatic Events Screening Inventory.

RESULTS

Six ACE items were individually predictive of a clinical-range Pediatric Symptom Checklist score after adjusting for sociodemographic covariates: emotional abuse or neglect (OR 2.93, 95% CI 1.32-6.52, P < .01), natural disaster (OR 3.89, 95% CI 1.18-12.76, P = .02), forced separation from a parent or caregiver (OR 2.95, 95% CI 1.50-5.83, P < .01), incarceration of a family member (OR 2.43, 95% CI 1.20-4.93, P = .01), physical attack (OR 2.84, 95% CI 1.32-6.11, P < .01), and community violence (OR 2.35, 95% CI 1.18-4.65, P = .01). After adjusting for overall ACE level, only 1 item remained statistically significant: forced separation from a parent or caregiver (OR 2.44, 95% CI 1.19-5.01, P = .02).

CONCLUSIONS

ACEs that disrupt attachment relationships between children and their caregivers are a significant predictor of risk for child emotional or behavioral problems.

Psychiatric Readmission of Children and Adolescents: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate predictors of psychiatric hospital readmission of children and adolescents, a systematic review and meta-analysis was conducted.

METHODS

Following PRISMA statement guidelines, a systematic literature search of articles published between 1997 and 2018 was conducted in PubMed/MEDLINE, Google Scholar, and PsycINFO for original peer-reviewed articles investigating predictors of psychiatric hospital readmission among youths (<18 years old). Effect sizes were extracted and combined by using random-effects meta-analysis. Covariates were investigated with meta-regression and subgroup analyses.

RESULTS

Thirty-three studies met inclusion criteria, containing information on 83,361 children and adolescents, of which raw counts of readmitted vs. non-readmitted youths were available for 76,219. Of these youths, 13.2% (N=10,076) were readmitted. The mean±SD study follow-up was 15.9±15.0 months, and time to readmission was 13.1±12.8 months. Readmission was associated with, but not limited to, suicidal ideation at index hospitalization (pooled odds ratio [OR_pooled]=2.35, 95% confidence interval [CI]=1.64-3.37), psychotic disorders (OR_pooled=1.87, 95% CI=1.53-2.28), prior hospitalization (OR_pooled=2.51, 95% CI=1.76-3.57), and discharge to residential treatment (OR_pooled=1.84, 95% CI=1.07-3.16). There was evidence of moderate study bias. Prior investigations were methodologically and substantively heterogeneous, particularly for measurement of family-level factors.

CONCLUSIONS

Interventions to reduce child psychiatric readmissions should place priority on youths with indicators of high clinical severity, particularly with a history of suicidality, psychiatric comorbidity, prior hospitalization, and discharge to residential treatment. Standardization of methods to determine prevalence rates of readmissions and their predictors is needed to mitigate potential biases and inform a national strategy to reduce repeated child psychiatric hospital readmissions.

Receipt of Addiction Treatment After Opioid Overdose Among Medicaid-Enrolled Adolescents and Young Adults

IMPORTANCE

Nonfatal opioid overdose may be a critical touch point when youths who have never received a diagnosis of opioid use disorder can be engaged in treatment. However, the extent to which youths (adolescents and young adults) receive timely evidence-based treatment following opioid overdose is unknown.

OBJECTIVE

To identify characteristics of youths who experience nonfatal overdose with heroin or other opioids and to assess the percentage of youths receiving timely evidence-based treatment.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used the 2009-2015 Truven-IBM Watson Health MarketScan Medicaid claims database from 16 deidentified states representing all US census regions. Data from 4 039 216 Medicaid-enrolled youths aged 13 to 22 years were included and were analyzed from April 20, 2018, to March 21, 2019.

EXPOSURES

Nonfatal incident and recurrent opioid overdoses involving heroin or other opioids.

MAIN OUTCOMES AND MEASURES

Receipt of timely addiction treatment (defined as a claim for behavioral health services, for buprenorphine, methadone, or naltrexone prescription or administration, or for both behavioral health services and pharmacotherapy within 30 days of incident overdose). Sociodemographic and clinical characteristics associated with receipt of timely treatment as well as with incident and recurrent overdoses were also identified.

RESULTS

Among 3791 youths with nonfatal opioid overdose, 2234 (58.9%) were female, and 2491 (65.7%) were non-Hispanic white. The median age was 18 years (interquartile range, 16-20 years). The crude incident opioid overdose rate was 44.1 per 100 000 person-years. Of these 3791 youths, 1001 (26.4%) experienced a heroin overdose; the 2790 (73.6%) remaining youths experienced an overdose involving other opioids. The risk of recurrent overdose among youths with incident heroin involvement was significantly higher than that among youths with other opioid overdose (adjusted hazard ratio, 2.62; 95% CI, 2.14-3.22), and youths with incident heroin overdose experienced recurrent overdose at a crude rate of 20 700 per 100 000 person-years. Of 3606 youths with opioid-related overdose and continuous enrollment for at least 30 days after overdose, 2483 (68.9%) received no addiction treatment within 30 days after incident opioid overdose, whereas only 1056 youths (29.3%) received behavioral health services alone, and 67 youths (1.9%) received pharmacotherapy. Youths with heroin overdose were significantly less likely than youths with other opioid overdose to receive any treatment after their overdose (adjusted odds ratio, 0.64; 95% CI, 0.49-0.83).

CONCLUSIONS AND RELEVANCE

After opioid overdose, less than one-third of youths received timely addiction treatment, and only 1 in 54 youths received recommended evidence-based pharmacotherapy. Interventions are urgently needed to link youths to treatment after overdose, with priority placed on improving access to pharmacotherapy.

Community Interventions to Promote Mental Health and Social Equity

(Reprinted with permission from Current Psychiatry Reports (2020) 21: 35).

Treatment for Nicotine Use Disorder Among Medicaid-Enrolled Adolescents and Young Adults

This study assesses use of nicotine replacement therapy, varenicline, and sustained-release bupropion for adolescents and young adults with nicotine use disorder who are enrolled in Medicaid.

Depression, Anxiety, and Emergency Department Use for Asthma

BACKGROUND AND OBJECTIVES

Asthma is responsible for ∼1.7 million emergency department (ED) visits annually in the United States. Studies in adults have shown that anxiety and depression are associated with increased asthma-related ED use. Our objective was to assess this association in pediatric patients with asthma.

METHODS

We identified patients aged 6 to 21 years with asthma in the Massachusetts All-Payer Claims Database for 2014 to 2015 using International Classification of Diseases, Ninth and 10th Revision codes. We examined the association between the presence of anxiety, depression, or comorbid anxiety and depression and the rate of asthma-related ED visits per 100 child-years using bivariate and multivariable analyses with negative binomial regression.

RESULTS

Of 65 342 patients with asthma, 24.7% had a diagnosis of anxiety, depression, or both (11.2% anxiety only, 5.8% depression only, and 7.7% both). The overall rate of asthma-related ED use was 17.1 ED visits per 100 child-years (95% confidence interval [CI]: 16.7-17.5). Controlling for age, sex, insurance type, and other chronic illness, patients with anxiety had a rate of 18.9 (95% CI: 17.0-20.8) ED visits per 100 child-years, patients with depression had a rate of 21.7 (95% CI: 18.3-25.0), and patients with both depression and anxiety had a rate of 27.6 (95% CI: 24.8-30.3). These rates were higher than those of patients who had no diagnosis of anxiety or depression (15.5 visits per 100 child-years; 95% CI: 14.5-16.4; P < .001).

CONCLUSIONS

Children with asthma and anxiety or depression alone, or comorbid anxiety and depression, have higher rates of asthma-related ED use compared with those without either diagnosis.

Utilization of Child Psychiatry Consultation Embedded in Primary Care for an Urban, Latino Population

OBJECTIVE

In a novel model of embedded primary care child psychiatry serving an urban Latino population, we examined determinants of successful referral and relationship between clinical need and service intensity.

METHODS

We conducted a chart review of referred patients from July 2013-March 2015. We used multiple logistic regressions controlling for confounders to identify determinants of successful referral. We examined the relationship between service intensity and clinical need using Poisson regression, adjusting for exposure time, age, sex, ethnicity, and language.

RESULTS

Seventy-four percent of patients completed an evaluation. Younger children (p=.0397) and those with a history of therapy (p=.0077) were more likely to make initial contact. The markers of clinical need included PSC-35 Global Scores (p=.0027) and number of psychiatric diagnoses (p=.0178) predicted number of visits.

CONCLUSIONS

Our findings support early referral to improve engagement, and provide initial evidence that embedded child psychiatry consultation is feasible and may increase access to care.

Selection of a Child Clinical Outcome Measure for Statewide Use in Publicly Funded Outpatient Mental Health Programs

OBJECTIVE

This study describes the process of choosing a clinical outcome measure for a statewide performance outcome system for children receiving publicly funded mental health services in California.

METHODS

The recommendation is based on a five-phase approach, including an environmental scan of measures used by state mental health agencies; a statewide provider survey; a scientific literature review; a modified Delphi panel; and final rating of candidate measures by using nine minimum criteria informed by stakeholder priorities, scientific evidence, and state statute.

RESULTS

Only 10 states reported use of at least one standardized measure for outcome measurement. In California, the most frequently reported measures were the Child and Adolescent Needs and Strengths (CANS) (N=33), the Child Behavior Checklist (N=14), and the Eyberg Child Behavior Inventory (N=12). Based on modified Delphi panel ratings, only the Achenbach System of Empirically Based Assessment, the Strengths and Difficulties Questionnaire, and the Pediatric Symptom Checklist (PSC) were rated on average in the high-equivocal to high range on effective care, scientific acceptability, usability, feasibility, and overall utility. The PSC met all nine minimum criteria for recommendation for statewide use. In its final decision, the California Department of Health Care Services mandated use of the PSC and CANS.

CONCLUSIONS

There is a lack of capacity to compare child clinical outcomes across states and California counties. Frequently used outcome measures were often not supported by scientific evidence or Delphi panel ratings. Policy action is needed to promote the selection of a common clinical outcome measure and measurement methodology for children receiving publicly funded mental health care.

Validation of the Traumatic Events Screening Inventory for ACEs

OBJECTIVES

Our purpose in this study was to adapt and validate the Traumatic Events Screening Inventory (TESI) as a primary-care childhood adversity screening tool for children living in vulnerable neighborhoods using a community-partnered approach.

METHODS

In this cross-sectional, descriptive study, we used a sample of 261 children (3-16 years old) who were seeking services at a Federally Qualified Health Center with colocated behavioral health services in Chicago and had a positive Pediatric Symptom Checklist screen result or received a referral for behavioral health evaluation. The TESI was adapted as a screening tool to be sensitive to adverse childhood experiences (ACEs) unique to the clinic communities. ACEs were mapped by zip code with objective neighborhood crime data, and latent class analysis was performed to identify ACE subgroups.

RESULTS

The mapping validation suggested face validity for geographic overlap between participant ACEs and objective violent-crime occurrence. With latent class analysis, we identified 3 ACE subgroups: (1) high ACE (18.0% of the sample; polyvictimization and/or maltreatment), (2) moderate ACE (52.1%; violent environments), and (3) low ACE (29.9%; few adverse experiences). Membership in the high-ACE subgroup was associated with higher odds of a clinically significant Pediatric Symptom Checklist score (odds ratio = 3.83) and clinical-level attention problems (odds ratio = 3.58) even after accounting for child resilience and parent depression.

CONCLUSIONS

ACEs play a significant role in predicting a need for behavioral health services among children seeking primary-care services. The community-adapted TESI is a valid ACE screening tool.

Community Interventions to Promote Mental Health and Social Equity

PURPOSE OF REVIEW

We review recent community interventions to promote mental health and social equity. We define community interventions as those that involve multi-sector partnerships, emphasize community members as integral to the intervention, and/or deliver services in community settings. We examine literature in seven topic areas: collaborative care, early psychosis, school-based interventions, homelessness, criminal justice, global mental health, and mental health promotion/prevention. We adapt the social-ecological model for health promotion and provide a framework for understanding the actions of community interventions.

RECENT FINDINGS

There are recent examples of effective interventions in each topic area. The majority of interventions focus on individual, family/interpersonal, and program/institutional social-ecological levels, with few intervening on whole communities or involving multiple non-healthcare sectors. Findings from many studies reinforce the interplay among mental health, interpersonal relationships, and social determinants of health. There is evidence for the effectiveness of community interventions for improving mental health and some social outcomes across social-ecological levels. Studies indicate the importance of ongoing resources and training to maintain long-term outcomes, explicit attention to ethics and processes to foster equitable partnerships, and policy reform to support sustainable healthcare-community collaborations.

A Telehealth-Enhanced Referral Process in Pediatric Primary Care: A Cluster Randomized Trial

: media-1vid110.1542/5984243450001PEDS-VA_2018-2738Video Abstract OBJECTIVES: To improve the mental health (MH) referral process for children referred from primary care to community mental health clinics (CMHCs) by using a community-partnered approach.

METHODS

Our partners were a multisite federally qualified health center and 2 CMHCs in Los Angeles County. We randomly assigned 6 federally qualified health center clinics to the intervention or as a control and implemented a newly developed telehealth-enhanced referral process (video orientation to the CMHC and a live videoconference CMHC screening visit) for all MH referrals from the intervention clinics. Our primary outcome was CMHC access defined by completion of the initial access point for referral (CMHC screening visit). We used multivariate logistic and linear regression to examine intervention impact on our primary outcome. To accommodate the cluster design, we used mixed-effect regression models.

RESULTS

A total of 342 children ages 5 to 12 were enrolled; 86.5% were Latino, 61.7% were boys, and the mean age at enrollment was 8.6 years. Children using the telehealth-enabled referral process had 3 times the odds of completing the initial CMHC screening visit compared with children who were referred by using usual care procedures (80.49% vs 64.04%; adjusted odds ratio 3.02 [95% confidence interval 1.47 to 6.22]). Among children who completed the CMHC screening visit, intervention participants took 6.6 days longer to achieve it but also reported greater satisfaction with the referral system compared with controls. Once this initial access point in referral was completed, >80% of eligible intervention and control participants (174 of 213) went on to an MH visit.

CONCLUSIONS

A novel telehealth-enhanced referral process developed by using a community-partnered approach improved initial access to CMHCs for children referred from primary care.

National Child Mental Health Quality Measures: Adherence Rates and Extent of Evidence for Clinical Validity

PURPOSE OF REVIEW

To provide an overview of the selection process and annual updates of the child mental health measures within the Child Core Set, describe national and statewide adherence rates, and summarize findings from a systematic literature review examining measure adherence rates and whether adherence is associated with improved clinical outcomes.

RECENT FINDINGS

Five national quality measures target child mental health care processes. On average, national adherence varied widely by state, and performance did not substantially improve during the past 5 years. Mean national adherence rates for the two measures related to timeliness of care were below 50%. For each measure, scientific evidence to support the association between adherence and improved clinical outcomes was scarce. Investment in academic-agency partnered research to standardize methods for publicly reporting adherence to national child mental health quality measures and validation of these measures should be a national priority for child healthcare research.

Trends in Pediatric Emergency Department Visits for Mental Health Conditions and Disposition by Presence of a Psychiatric Unit

OBJECTIVE

To examine trends in mental health (MH) visits to pediatric emergency departments (EDs) and identify whether ED disposition varies by presence of a hospital inpatient psychiatric unit (IPU).

STUDY DESIGN

Cross-sectional study of 8,479,311 ED visits to 35 children's hospitals from 2012 to 2016 for patients aged 3 to 21 years with a primary MH or non-MH diagnosis. Multivariable generalized estimating equations and bivariate Rao-Scott chi-square tests were used to examine trends in ED visits and ED disposition by IPU status, adjusted for clustering by hospital.

RESULTS

From 2012 to 2016, hospitals experienced a greater increase in ED visits with a primary MH versus non-MH diagnosis (50.7% vs 12.7% cumulative increase, P < .001). MH visits were associated with patients who were older, female, white non-Hispanic, and privately insured compared with patients of non-MH visits (all P < .001). Forty-four percent of MH visits in 2016 had a primary diagnosis of depressive disorders or suicide or self-injury, and the increase in visits was highest for these diagnosis groups (depression: 109.8%; suicide or self-injury: 110.2%). Among MH visits, presence of a hospital IPU was associated with increased hospitalizations (34.6% vs 22.5%, P < .001) and less transfers (9.2% vs 16.2%, P < .001).

CONCLUSION

The increase in ED MH visits from 2012 to 2016 was 4 times greater than non-MH visits at US children's hospitals and was primarily driven by patients diagnosed with depressive disorders and suicide or self-injury. Our findings have implications for strategic planning in tertiary children's hospitals dealing with a rising demand for acute MH care.

Readmissions after Pediatric Hospitalization for Suicide Ideation and Suicide Attempt

OBJECTIVE

To inform resource allocation toward a continuum of care for youth at risk of suicide, we examined unplanned 30-day readmissions after pediatric hospitalization for either suicide ideation (SI) or suicide attempt (SA).

METHODS

We conducted a retrospective cohort study of a nationally representative sample of 133,516 hospitalizations for SI or SA among 6- to 17-year-olds to determine prevalence, risk factors, and characteristics of 30-day readmissions using the 2013 and 2014 Nationwide Readmissions Dataset (NRD). Risk factors for readmission were modeled using logistic regression.

RESULTS

We identified 95,354 hospitalizations for SI and 38,162 hospitalizations for SA. Readmission rates within 30 days were 8.5% for SI and SA hospitalizations. Among 30-day readmissions, more than one-third (34.1%) occurred within 7 days. Among patients with any 30-day readmission, 11% had more than one readmission within 30 days. The strongest risk factors for readmission were SI or SA hospitalization in the 30 days preceding the index SI/SA hospitalization (adjusted odds ratio [AOR]: 3.14, 95% CI: 2.73-3.61) and hospitalization for other indications in the previous 30 days (AOR: 3.18, 95% CI: 2.67-3.78). Among readmissions, 94.5% were for a psychiatric condition and 63.4% had a diagnosis of SI or SA.

CONCLUSIONS

Quality improvement interventions to reduce unplanned 30-day readmissions among children hospitalized for SI or SA should focus on children with a recent prior hospitalization and should be targeted to the first week following hospital discharge.

FUNDING

Dr. Zima received funding from the Behavioral Health Centers of Excellence for California (SB852).

Receipt of Timely Addiction Treatment and Association of Early Medication Treatment With Retention in Care Among Youths With Opioid Use Disorder

Importance

Retention in addiction treatment is associated with reduced mortality for individuals with opioid use disorder (OUD). Although clinical trials support use of OUD medications among youths (adolescents and young adults), data on timely receipt of buprenorphine hydrochloride, naltrexone hydrochloride, and methadone hydrochloride and its association with retention in care in real-world treatment settings are lacking.

Objectives

To identify the proportion of youths who received treatment for addiction after diagnosis and to determine whether timely receipt of OUD medications is associated with retention in care.

Design, Setting, and Participants

This retrospective cohort study used enrollment data and complete health insurance claims of 2.4 million youths aged 13 to 22 years from 11 states enrolled in Medicaid from January 1, 2014, to December 31, 2015. Data analysis was performed from August 1, 2017, to March 15, 2018.

Exposures

Receipt of OUD medication (buprenorphine, naltrexone, or methadone) within 3 months of diagnosis of OUD compared with receipt of behavioral health services alone.

Main Outcomes and Measures

Retention in care, with attrition defined as 60 days or more without any treatment-related claims.

Results

Among 4837 youths diagnosed with OUD, 2752 (56.9%) were female and 3677 (76.0%) were non-Hispanic white. Median age was 20 years (interquartile range [IQR], 19-21 years). Overall, 3654 youths (75.5%) received any treatment within 3 months of diagnosis of OUD. Most youths received only behavioral health services (2515 [52.0%]), with fewer receiving OUD medications (1139 [23.5%]). Only 34 of 728 adolescents younger than 18 years (4.7%; 95% CI, 3.1%-6.2%) and 1105 of 4109 young adults age 18 years or older (26.9%; 95% CI, 25.5%-28.2%) received timely OUD medications. Median retention in care among youths who received timely buprenorphine was 123 days (IQR, 33-434 days); naltrexone, 150 days (IQR, 50-670 days); and methadone, 324 days (IQR, 115-670 days) compared with 67 days (IQR, 14-206 days) among youths who received only behavioral health services. Timely receipt of buprenorphine (adjusted hazard ratio, 0.58; 95% CI, 0.52-0.64), naltrexone (adjusted hazard ratio, 0.54; 95% CI, 0.43-0.69), and methadone (adjusted hazard ratio, 0.32; 95% CI, 0.22-0.47) were each independently associated with lower attrition from treatment compared with receipt of behavioral health services alone.

Conclusions and Relevance

Timely receipt of buprenorphine, naltrexone, or methadone was associated with greater retention in care among youths with OUD compared with behavioral treatment only. Strategies to address the underuse of evidence-based medications for youths with OUD are urgently needed.

Medicaid Expenditures Among Children With Noncomplex Chronic Diseases

BACKGROUND AND OBJECTIVES

Expenditures for children with noncomplex chronic diseases (NC-CDs) are related to disease chronicity and resource use. The degree to which specific conditions contribute to high health care expenditures among children with NC-CDs is unknown. We sought to describe patient characteristics, expenditures, and use patterns of children with NC-CDs with the lowest (≤80th percentile), moderate (81-95th percentile), high (96-99th percentile), and the highest (≥99th percentile) expenditures.

METHODS

In this retrospective cross-sectional study, we used the 2014 Truven Medicaid MarketScan Database for claims from 11 states. We included continuously enrolled children (age <18 years) with NC-CDs (n = 1 563 233). We describe per member per year (PMPY) spending and use by each expenditure group for inpatient services, outpatient services, and the pharmacy for physical and mental health conditions. K-means clustering was used to identify expenditure types for the highest expenditure group.

RESULTS

Medicaid PMPY spending ranged from $1466 (lowest expenditures) to $57 300 (highest expenditures; P < .001); children in the highest expenditure group were diagnosed with a mental health condition twice as often (72.7% vs 34.1%). Cluster analysis was used to identify 3 distinct groups: 83% with high outpatient mental health expenditures (n = 13 033; median PMPY $18 814), 15% with high inpatient expenditures (n = 2386; median PMPY $92 950), and 1% with high pharmacy expenditures (n = 213; median $325 412). Mental health conditions accounted for half of the inpatient diagnoses in the cluster analysis.

CONCLUSIONS

One percent of children with the highest expenditures accounted for 20% of Medicaid expenditures in children with NC-CDs; mental health conditions account for a large proportion of aggregate Medicaid spending in children with NC-CDs.

Development of a Telehealth-Coordinated Intervention to Improve Access to Community-Based Mental Health

Objective

To develop an intervention to improve the mental health referral and care process for children referred by primary care providers (PCPs) to community mental health clinics (MHCs) using a community partnered approach.

Design

A Project Working Group (PWG) with representatives from each partner organization met monthly for 6 months.

Setting

Multi-site federally qualified health center (FQHC) and two community MHCs in Los Angeles county.

Participants

26 stakeholders (14 FQHC clinic providers/staff, 8 MHC providers/staff, 4 parents) comprised the PWG.

Data Sources

Qualitative interviews, PWG meeting notes, intervention processes and workflow reports.

Intervention

The PWG reviewed qualitative data from stakeholders (interviews of 7 parents and 13 providers/staff). The PWG met monthly to identify key transition points where access to and coordination of care were likely compromised and to develop solutions.

Results

Three critical transition points and system solutions were identified: 1) Parents refuse initial referral to the MHC due to stigma regarding mental health services. Solution: During initial referral, parents watch a video introducing them to the MHC. 2) Parents don't complete the MHC's screening after referral. Solution: A live videoconference session connecting parents at the FQHC with MHC staff ensures completion of the screening and eligibility process. 3) PCPs reject transfer of patients back to primary care for ongoing psychotropic medication management. Solution: Regularly scheduled live videoconferences connect PCPs and MHC providers.

Conclusions

A community partnered approach to care design utilizing telehealth for care coordination between clinics can potentially be used to address key challenges in MHC access for children.

Development and Evaluation of Two Integrated Care Models for Children Using a Partnered Formative Evaluation Approach

Objective

To describe the development and evaluation of two integrated care models using a partnered formative evaluation approach across a private foundation, clinic leaders, providers and staff, and a university-based research center.

Design

Retrospective cohort study using multiple data sources.

Setting

Two federal qualified health care centers serving low-income children and families in Chicago.

Participants

Private foundation, clinic and academic partners.

Interventions

Development of two integrated care models and partnered evaluation design.

Main Outcome Measures

Accomplishments and early lessons learned.

Results

Together, the foundation-clinic-academic partners worked to include best practices in two integrated care models for children while developing the evaluation design. A shared data collection approach, which empowered the clinic partners to collect data using a web-based tool for a prospective longitudinal cohort study, was also created.

Conclusion

Across three formative evaluation stages, the foundation, clinic, and academic partners continued to reach beyond their respective traditional roles of project oversight, clinical service, and research as adjustments were collectively made to accommodate barriers and unanticipated events. Together, an innovative shared data collection approach was developed that extends partnered research to include data collection being led by the clinic partners and supported by the technical resources of a university-based research center.

Evaluation of the Mental Health Services Act in Los Angeles County: Implementation and Outcomes for Key Programs

Los Angeles County used Mental Health Services Act (MHSA) funds to greatly expand access to Full-Service Partnership (FSP) services and offer new prevention and early intervention (PEI) services. This study examines the reach of key MHSA-funded activities and what the impact of those activities has been, with a focus on PEI programs for children and transition-age youth (TAY) and FSP programs for children, TAY, and adults. The evaluation found evidence that the Los Angeles County Department of Mental Health (LAC DMH) is reaching the highly vulnerable population it seeks to reach with its FSP and youth PEI programs. Furthermore, those reached by the programs experience improvements in their mental health and life circumstances. Refining data collection will enable more-thorough evaluation of processes of care and would inform the program's quality-improvement efforts.

Mental Health Conditions and Unplanned Hospital Readmissions in Children

OBJECTIVE

Mental health conditions (MHCs) are prevalent among hospitalized children and could influence the success of hospital discharge. We assessed the relationship between MHCs and 30-day readmissions.

METHODS

This retrospective, cross-sectional study of the 2013 Nationwide Readmissions Database included 512,997 hospitalizations of patients ages 3 to 21 years for the 10 medical and 10 procedure conditions with the highest number of 30-day readmissions. MHCs were identified by using the International Classification of Diseases, 9th Revision-Clinical Modification codes. We derived logistic regression models to measure the associations between MHC and 30-day, all-cause, unplanned readmissions, adjusting for demographic, clinical, and hospital characteristics.

RESULTS

An MHC was present in 17.5% of medical and 13.1% of procedure index hospitalizations. Readmission rates were 17.0% and 6.2% for medical and procedure hospitalizations, respectively. In the multivariable analysis, compared with hospitalizations with no MHC, hospitalizations with MHCs had higher odds of readmission for medical admissions (adjusted odds ratio [AOR], 1.23; 95% confidence interval [CI], 1.19-1.26] and procedure admissions (AOR, 1.24; 95% CI, 1.15-1.33). Three types of MHCs were associated with higher odds of readmission for both medical and procedure hospitalizations: depression (medical AOR, 1.57; 95% CI, 1.49-1.66; procedure AOR, 1.39; 95% CI, 1.17-1.65), substance abuse (medical AOR, 1.24; 95% CI, 1.18-1.30; procedure AOR, 1.26; 95% CI, 1.11-1.43), and multiple MHCs (medical AOR, 1.43; 95% CI, 1.37-1.50; procedure AOR, 1.26; 95% CI, 1.11-1.44).

CONCLUSIONS

MHCs are associated with a higher likelihood of hospital readmission in children admitted for medical conditions and procedures. Understanding the influence of MHCs on readmissions could guide strategic planning to reduce unplanned readmissions for children with cooccurring physical and mental health conditions.

Office Visits to Monitor Stimulant Medication Safety and Efficacy: Recommended Care

The clinical guidance based on the research article, "Specific Components of Pediatricians' Medication-Related Care Predict Attention-Deficit/Hyperactivity Disorder Improvement," published in the June 2017 issue,¹ might be premature. The authors, Epstein et al., suggest that "Physicians do not need to necessarily rely on office visits to monitor medication response and side effects in the week(s) after initially prescribing medication, but instead could use phone calls or email correspondence to check in with the family" (p. 489). However, this advice has the potential to be misinterpreted that phone or email contact is acceptable clinical practice to monitor stimulant medication safety and efficacy, especially during the maintenance phase. It also could be erroneously interpreted that phone or email contact is sufficient for follow-up care for children receiving medication treatment for attention-deficit/hyperactivity disorder (ADHD) for national quality measures.

High-Expenditure Pharmaceutical Use Among Children in Medicaid

BACKGROUND AND OBJECTIVES

Medication use may be a target for quality improvement, cost containment, and research. We aimed to identify medication classes associated with the highest expenditures among pediatric Medicaid enrollees and to characterize the demographic, clinical, and health service use of children prescribed these medications.

METHODS

Retrospective, cross-sectional study of 3 271 081 Medicaid-enrolled children. Outpatient medication spending among high-expenditure medication classes, defined as the 10 most expensive among 261 mutually exclusive medication classes, was determined by using transaction prices paid to pharmacies by Medicaid agencies and managed care plans among prescriptions filled and dispensed in 2013.

RESULTS

Outpatient medications accounted for 16.6% of all Medicaid expenditures. The 10 most expensive medication classes accounted for 63.9% of all medication expenditures. Stimulants (amphetamine-type) accounted for both the highest proportion of expenditures (20.6%) and days of medication use (14.0%) among medication classes. Users of medications in the 10 highest-expenditure classes were more likely to have a chronic condition of any complexity (77.9% vs 41.6%), a mental health condition (35.7% vs 11.9%), or a complex chronic condition (9.8% vs 4.3%) than other Medicaid enrollees (all P < .001). The 4 medications with the highest spending were all psychotropic medications. Polypharmacy was common across all high-expenditure classes.

CONCLUSIONS

Medicaid expenditure on pediatric medicines is concentrated among a relatively small number of medication classes most commonly used in children with chronic conditions. Interventions to improve medication safety and effectiveness and contain costs may benefit from better delineation of the appropriate prescription of these medications.

Poverty and Trends in Three Common Chronic Disorders

OBJECTIVES

For asthma, attention-deficit/hyperactivity disorder (ADHD), and autism spectrum disorder (ASD), the objectives were to (1) describe the percent increases in prevalence and comorbidity and how these vary by poverty status, and (2) examine the extent to which poverty status is a predictor of higher than average comorbid conditions.

METHODS

Secondary analyses of the National Survey of Children's Health for years 2003, 2007, and 2011-2012 were conducted to identify trends in parent reported lifetime prevalence and comorbidity among children with asthma, ADHD, and ASD and examine variation by sociodemographic characteristics, poverty status, and insurance coverage. Using 2011-2012 data, multivariable regression was used to examine whether poverty status predicted higher than average comorbid conditions after adjusting for other sociodemographic characteristics.

RESULTS

Parent-reported lifetime prevalence of asthma and ADHD rose 18% and 44%, respectively, whereas the lifetime prevalence of ASD rose almost 400% (from 0.5% to 2%). For asthma, the rise was most prominent among the poor at 25.8%. For ADHD, the percent change by poverty status was similar (<100% federal poverty level [FPL]: 43.20%, 100% to 199% FPL: 52.38%, 200% to 399% FPL: 43.67%), although rise in ASD was associated with being nonpoor (200% to 399% FPL: 43.6%, ≥400% FPL: 36.0%). Publicly insured children with asthma, ADHD, and ASD also had significantly higher odds (1.9×, 1.6×, 3.0×, respectively) of having higher than average comorbidities.

CONCLUSIONS

Poverty status differentially influenced parent-reported lifetime prevalence and comorbidities of these target disorders. Future research is needed to examine parent and system-level characteristics that may further explain poverty's variable impact.

State-to-State Variation in SSI Enrollment for Children With Mental Disabilities: An Administrative and Ethical Challenge

OBJECTIVE

The study examined state variation in rates of Supplemental Security Income (SSI) determinations, allowances, and receipt of benefits for ten selected child mental disabilities in 2013.

METHODS

SSI administrative and U.S. Census Bureau data collected by a multidisciplinary consensus committee convened by the National Academies of Science, Engineering, and Medicine in 2015 were examined.

RESULTS

Less than 1% of children in 2013 were recipients of SSI for mental disabilities. Determination rates ranged from 1,441 to 251 per 100,000 low-income children, an almost sixfold difference. Allowance rates varied from 16% to 78%, a fivefold difference. Receipt of benefits ranged from .7% to 5.3%, a sevenfold difference.

CONCLUSIONS

Large unexplained discrepancies across states were found in review and receipt of SSI benefits for low-income children with mental disabilities. Inequities that cannot be explained by disability severity or financial need violate the ethos of equitable access to federally entitled services.

Mental Health Conditions and Medical and Surgical Hospital Utilization

OBJECTIVE

Mental health conditions are prevalent among children hospitalized for medical conditions and surgical procedures, but little is known about their influence on hospital resource use. The objectives of this study were to examine how hospitalization characteristics vary by presence of a comorbid mental health condition and estimate the association of a comorbid mental health condition with hospital length of stay (LOS) and costs.

METHODS

Using the 2012 Kids' Inpatient Database, we conducted a retrospective, nationally representative, cross-sectional study of 670 161 hospitalizations for 10 common medical and 10 common surgical conditions among 3- to 20-year-old patients. Associations between mental health conditions and hospital LOS were examined using adjusted generalized linear models. Costs of additional hospital days associated with mental health conditions were estimated using hospital cost-to-charge ratios.

RESULTS

A comorbid mental health condition was present in 13.2% of hospitalizations. A comorbid mental health condition was associated with a LOS increase of 8.8% (from 2.5 to 2.7 days, P < .001) for medical hospitalizations and a 16.9% increase (from 3.6 to 4.2 days, P < .001) for surgical hospitalizations. For hospitalizations in this sample, comorbid mental health conditions were associated with an additional 31 729 (95% confidence interval: 29 085 to 33 492) hospital days and $90 million (95% confidence interval: $81 to $101 million) in hospital costs.

CONCLUSIONS

Medical and surgical hospitalizations with comorbid mental health conditions were associated with longer hospital stay and higher hospital costs. Knowledge about the influence of mental health conditions on pediatric hospital utilization can inform clinical innovation and case-mix adjustment.

Psychiatric Disorders and Trends in Resource Use in Pediatric Hospitals

OBJECTIVE

To describe recent, 10-year trends in pediatric hospital resource use with and without a psychiatric diagnosis and examine how these trends vary by type of psychiatric and medical diagnosis cooccurrence.

METHODS

A retrospective, longitudinal cohort analysis using hospital discharge data from 33 tertiary care US children's hospitals of patients ages 3 to 17 years from January 1, 2005 through December 31, 2014. The trends in hospital discharges, hospital days, and total aggregate costs for each psychiatric comorbid group were assessed by using multivariate generalized estimating equations.

RESULTS

From 2005 to 2014, the cumulative percent growth in resource use was significantly (all P < .001) greater for children hospitalized with versus without a psychiatric diagnosis (hospitalizations: +137.7% vs +26.0%; hospital days: +92.9% vs 5.9%; and costs: +142.7% vs + 18.9%). During this time period, the most substantial growth was observed in children admitted with a medical condition who also had a cooccurring psychiatric diagnosis (hospitalizations: +160.5%; hospital days: +112.4%; costs: +156.2%). In 2014, these children accounted for 77.8% of all hospitalizations for children with a psychiatric diagnosis; their most common psychiatric diagnoses were developmental disorders (22.3%), attention-deficit/hyperactivity disorder (18.1%), and anxiety disorders (14.2%).

CONCLUSIONS

The 10-year rise in pediatric hospitalizations in US children's hospitals is 5 times greater for children with versus without a psychiatric diagnosis. Strategic planning to meet the rising demand for psychiatric care in tertiary care children's hospitals should place high priority on the needs of children with a primary medical condition and cooccurring psychiatric disorders.