Mental Health Revisits at US Pediatric Emergency Departments

Abstract

ImportancePediatric emergency department (ED) visits for mental health crises are increasing. Patients who frequently use the ED are of particular concern, as pediatric mental health ED visits are commonly repeat visits. Better understanding of trends and factors associated with mental health ED revisits is needed for optimal resource allocation and targeting of prevention efforts.ObjectiveTo describe trends in pediatric mental health ED visits and revisits and to determine factors associated with revisits.Design, Setting, and ParticipantsIn this cohort study, data were obtained from 38 US children’s hospital EDs in the Pediatric Health Information System between October 1, 2015, and February 29, 2020. The cohort included patients aged 3 to 17 years with a mental health ED visit.ExposuresCharacteristics of patients, encounters, hospitals, and communities.Main Outcomes and MeasuresThe primary outcome was a mental health ED revisit within 6 months of the index visit. Trends were assessed using cosinor analysis and factors associated with time to revisit using mixed-effects Cox proportional hazards regression.ResultsThere were 308 264 mental health ED visits from 217 865 unique patients, and 13.2% of patients had a mental health revisit within 6 months. Mental health visits increased by 8.0% annually (95% CI, 4.5%-11.4%), whereas all other ED visits increased by 1.5% annually (95% CI, 0.1%-2.9%). Factors associated with mental health ED revisits included psychiatric comorbidities, chemical restraint use, public insurance, higher area measures of child opportunity, and presence of an inpatient psychiatric unit at the presenting hospital. Patients with psychotic disorders (hazard ratio [HR], 1.42; 95% CI, 1.29-1.57), disruptive or impulse control disorders (HR, 1.36; 95% CI, 1.30-1.42), and neurodevelopmental disorders (HR, 1.22; 95% CI, 1.14-1.30) were more likely to revisit. Patients with substance use disorders (HR, 0.60; 95% CI, 0.55-0.66) were less likely to revisit.Conclusions and RelevanceMarkers of disease severity and health care access were associated with mental health revisits. Directing hospital and community interventions toward identified high-risk patients is needed to help mitigate recurrent mental health ED use and improve mental health care delivery.

Consider R Codes for Undiagnosed Serious Pediatric Behavior Problems—Reply

“…In Reply We thank Carlson et al for their interest in our study . We agree with the need to accurately identify patients with behavioral outbursts to allow for further study of this important population.…”

“…Use of administrative data is inherently limited by the accuracy of diagnoses assigned by clinicians and by patient cohort definitions . Validated systems such as the Child and Adolescent Mental Health Disorders Classification System, which was used in our study, can help with phenotyping and identification of mental health patient cohorts, but need to be continually improved . The future adoption of International Classification of Diseases , 11th Revision provides an opportunity to further refine diagnosis codes pertaining to mental health conditions to improve their accuracy and usability.…”

Consider R Codes for Undiagnosed Serious Pediatric Behavior Problems

“…To the Editor The importance of impulse control disorders and social determinants of health in predicting emergency department visits for children, as reported by Cushing et al, further highlights the impact of impairing emotional outbursts on pediatric mental health. We recently found that, for 435 comprehensive psychiatric emergency program (CPEP) encounters for 339 children aged 5 to 12 years over a 9-month period, 22% were revisits and 28% were brought in by police .…”

“…Impairing emotional outbursts, characterized by extreme distress, agitation, and sometimes suicidal threats, are transdiagnostic and are not captured by 1 diagnosis. Cushing et al state that episodes of agitation may account for the emergency department revisits. They absolutely might.…”

Attention to Co-occurring Disorders, Crisis Care, and Adequate Funding May Bolster Pediatric Access to Behavioral Health Care—Reply

“…We agree that co-occurring substance use disorders, developmental disabilities, and physical health conditions exacerbate challenges in access to mental health services. Children with neurodevelopmental disorders, such as autism spectrum disorder, are more likely to revisit the emergency department for mental health conditions and are more likely to experience boarding (prolonged emergency department or inpatient stays awaiting mental health services) . Additionally, children with eating disorders may face challenges in accessing specialized services, as visits for these conditions have increased during the COVID-19 pandemic .…”