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

Abstract

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 followup. 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.WHAT'S KNOWN ON THIS SUBJECT: A nationally endorsed pediatric quality measure is used to assess rates of timely followup for patients hospitalized for a mental health diagnosis. Rates range from 48% to 67%, but little is known about variations by patient characteristics or about the relationship between followup and a subsequent psychiatric crisis.

Evaluating quality in adolescent mental health services: a systematic review

“…The services ranged from emergency, 52 58 to primary level 46 49 50 52 53 55 62 64 ; secondary level mental health services 45 48–52 54 57 60–64 and tertiary level services. 47 52 56 59 62 64 …”

“…The majority of studies were conducted in high-income countries, namely the USA (eight studies), [45][46][47][48][49][50][51][52] Australia (three studies), [53][54][55] UK (two studies), 56 57 Canada (two studies), 58 59 the Netherlands (two studies), 60 61 Ireland 62 and Switzerland (one study). 63 One study was conducted in Uganda.…”

“…46 47 53 54 56-61 64 Where it was conceptualised, it was in reference to high quality care, defined as healthcare provider fidelity to evidence-based treatment models and adolescents' engagement in the treatment process (satisfaction and quality of engagement with therapists and adolescents) 45 ; as quality indicators in terms of information and access, facilities and services and quality of care 62 ; as quality indicators in child and adolescent mental health services, specifically around patient satisfaction and quality engagement between the therapist and adolescent 63 ; or follow-up after hospitalisation for a mental illness. 52 Common themes within these studies were a focus on the processes of care and quality impacts (improved mental health and greater confidence of the health service and system). 16 Other studies mentioned quality in relation to patientcentred communication or how providers adapt their communication style to meet the needs and preferences of their patients.…”

“…Fifteen studies included outcomes relevant to healthcare provider competency. They focused on confidence in managing and referring adolescents with mental health issues, 58 greater collaboration between paediatricians and mental health clinicians, 59 use of evidence-based practices, [48][49][50][51][52] use of a tablet to facilitate adolescent patient engagement in therapy, 45 provision of information 53 60-62 and implementation of care models and plans. 46 57 64 The quality of evidence for the fifteen included studies ranged from poor to fair.…”

“…Adolescent patients were more likely to be followed-up after discharge from psychiatric units and hospitals compared with those from general medical or surgical units. 52 A 2-year child and adolescent mental health training programme for healthcare providers (psychiatric clinical officers, psychologists, psychiatric nurses, general nurses, occupational therapists, etc) was implemented in Uganda. 64 Medical records were reviewed annually over 6 years, finding that a greater number of children and adolescents were receiving thorough patient-centred assessments; a reduction in medication prescription; an increase in the use of psychological treatments and Open access greater management of cases by non-CAMHS professionals after the intervention.…”