Profiling Children and Adolescents with Serious
emotional Disturbances
Part II: Quality Assessment
FinaL Report
Cynthia A. Fontanella, Ph.D.
Danielle L. Hiance, MSW
Jeffrey Bridge, Ph.D.
John V. Campo, M.D.
Eric Seiber, Ph.D.
Jeff J. Guo, B. Pharm., Ph.D.
The Ohio State University
College of Social Work &
Department of Psychiatry, College of Medicine
TABLE OF CONTENTS
EXECUTIVE SUMMARy...... 2
INTRODUCTION ...... 6
STUDY AIMS AND OBJECTIVES …………………………………………...... 6
BACKGROUND ……………………………………………………...……….…...... 7 SIGNIFICANCE ...…………………………………………………………..….………. 8
METHODS …..…………………………………………………………………………………... 8
DEVELOPMENT OF QUALITY INDICATORS…………………………………….. 8
DATA FOR ESTIMATED CONFORMANCE RATES……………………..………... 12
QUALITY MEASURES………………………………………………………………… 12
Data ANALYSIS……………………………………………………………..………… 21
RESULTS …………………………………………………………………………...…...... 22
POPULATION CHARACTERISTICS……………………………………………….. 22
CONFORMANCE RATES…………………………………………………...... ……… 22
CONCLUSION …….………………………………………………………………….………… 27
ACKNOWLEDGEMENTS …..………………………………………………………………… 31
REFERENCES …..……………………………………………………………………………… 32
APPENDICES …...……………………………………………………………………………... 38
APPENDIX A: EXPERT PANEL…………………………….……………………….. 38
APPENDIX B: SAMPLE RATING SHEET…………………………………..……… 41
APPENDIX C: SUMMARY OF RATING SCORES…………………………...... 44
APPENDIX D: QUALITY OF CARE MEASURE PACKET………………………. 47
Executive Summary
background
An estimated 20% of youth (15 million) between the ages of 9 and 17 are diagnosed with a mental disorder, 9 to 13% (approximately 6 to 9 million) have significant functional impairments, and 5 to 9% have serious emotional disturbances. Despite the high prevalence of childhood mental disorders, costs, and availability of effective interventions, many youths receive inadequate treatment or no treatment at all. Epidemiological studies indicate that 75 to 80% of children between the ages of 6 to 17 with mental health disorders do not receive any mental health care, and rates of unmet need vary significantly by geographic region, ethnic group, and service sector.
Even when youths are able to access mental health services, quality of care is often poor. Empirically validated treatment exists for a number of major childhood conditions including: 1) ADHD; 2) depression; 3) anxiety disorders; and 4) conduct disorders. Over the past decade, there has also been a proliferation of clinical practice guidelines, quality indicators, and medication algorithms, all intended to improve quality of care by articulating evidence-based practices and by identifying the steps needed to implement optimal treatment. However, research has documented wide variations in quality of care including; a) failures to conform to evidence-based practice guidelines; b) underuse, overuse, and misuse of certain treatments; and c) racial and ethnic disparities in access and quality of care.
Study Objectives
The primary aim of this project was to assess patterns and quality of care received by children in Ohio’s public mental health system. Specific objectives included:
(1) To develop quality of care measures for common childhood diagnoses
(2) To describe the quality of care for specific diagnostic groups
Data and Methods
The development of the quality of care measures involved two phases. In the first phase, we conducted a systematic review of the scientific and clinical literature to identify quality indicators on treatment of the common childhood disorders: depression, bipolar disorder, attention deficit hyperactivity disorder, and anxiety. In addition, we also reviewed the literature on other relevant topics including questionable psychotropic prescribing practices, evidence-based treatment for preschoolers, and continuity of care. In the second phase, we convened an expert panel which was assigned to rate the quality indicators using the RAND Appropriateness Method.
To examine conformance rates for identified quality indicators, we used Ohio Medicaid claims data. The target population included all children and youth (aged 0-18) enrolled in Medicaid for at least one month between January 1, 2006 and December 31, 2010 who had a primary and/or secondary mental health diagnosis (ICD-9 CM 290-319) or one or more mental health claims or at least one psychotropic medication during the study period. Excluded were youth with a diagnosis of substance abuse (ICD _9_CM codes: 291, 292, 303, 304, 305) or mental retardation (ICD-9-CM codes: 315, 317-319) and no other mental health diagnosis.
Key Findings
Psychotropic Prescribing Practices
· Evidence of inappropriate psychotropic prescribing
Ø A total of 250,149 (29.3%) children and youth who were mental health users had one or more prescriptions for a psychotropic medication. Of this group, 5.4% were prescribed four or more psychotropic medications concurrently for 60 days or longer. Rates of polypharmacy were highest for the use of two or more antipsychotics (4.5%) and lowest for the use of two or more stimulants (0.39%).
· Most prescriptions for antipsychotic medications are for off-label use.
Ø Of those youth in Medicaid prescribed two or more antipsychotic medications concomitantly, 70.1% were for off-label use.
· Children in foster care are more vulnerable to poor quality of care than other aid groups.
Ø A greater proportion of children in foster care compared to nonfoster care children were prescribed: 1) four or more psychotropic medications concurrently; 2) two or more antipsychotic medications; and 3) dosages of medications higher than the recommended maximum. Rates of four or more medications concomitantly were 15.3% for children in foster care compared to 8.5% of youths in the ABD and adoptive care group, and 4.0% for youth in the CFC group.
Quality of care for Common Childhood Disorders
· Nonadherence with antidepressant medications is common among Medicaid-covered youth with depression. Research suggests that follow-up care is critical to ensure successful outcomes; however, many children do not receive adequate follow-up.
Ø Among youth newly diagnosed with depressive disorder, about half (47%) were adherent with their antidepressant treatment during the acute phase and about a quarter (24.3%) were adherent during the continuation phase. Only 27.6 % received at least 3 visits by their prescribing providers, and 43.1% had at least 6 outpatient psychotherapy visits. The overwhelming majority (85%) received an appropriate dose of antidepressant medication.
· Most children diagnosed with bipolar disorder do not receive medical monitoring.
Ø Among youth newly diagnosed with bipolar disorder and prescribed mood stabilizers during the acute phase of treatment, only about one-fifth received appropriate laboratory tests for blood levels or side effect monitoring (18.8% and 20.7%, respectively). Of those treated with antipsychotics, only 8.7% received glucose and lipids screening.
· Most children diagnosed with ADHD are prescribed the recommended first-line stimulants; however, follow-up after initiation of medication is poor.
Ø 85% of children diagnosed with ADHD were prescribed an amphetamine or methylphenidate-based stimulant.
Ø Only about a third of youth (32.9%) had at least one follow-up visit with a prescribing practitioner within 30 days of initiating the stimulant.
Quality of care for Preschoolers
· Most young children treated with psychotropic medications do not receive psychosocial treatment.
Ø The prevalence of antipsychotic use among children aged 2-5 was .78%. Of those young children prescribed antipsychotics, most (70.9%) were diagnosed with behavioral disorders.
Ø Of those young children prescribed psychotropic medications, only about one fifth (20.5%) had 6 or more psychosocial visits prior to initiating the medication and 54.6% had 6 or more psychosocial visits after initiating the medication.
Continuity of Care
· Most children with mental health problems admitted to the emergency room and/or hospital do not receive timely outpatient follow-up.
Ø Of the children admitted to the emergency room, only 38% (4 out of 10 children) received an outpatient follow-up within 30 days.
Ø Less than two-thirds (62.2%) receiving an outpatient visits after hospital discharge
Policy Implications
The findings provide important guidance for policy and practice to improve the quality of care for children and adolescents. Three main implications emerge from this study:
· Need for quality improvement efforts focused on inappropriate prescribing
The results from the study suggest that questionable psychotropic prescribing is common including the use of concomitant medications, doses that exceed the recommended maximum, and prescribing to children under age six. Such practices not only pose health risks but the effectiveness is virtually unknown. Quality improvement initiatives are needed to improve psychotropic prescribing practices, especially for children in foster care.
· Ensure that preschoolers have access to evidence-based psychosocial services.
Despite the availability of effective psychosocial treatments for young children such as parent management, problem solving, and multisystemic therapy for aggression, our data suggests that nonpharmacological services are being underutilized, contrary to existing guidelines. Ensuring access to psychosocial interventions is critical for successful outcomes for young children.
· Promote continuity of care during high-risk periods, including following an emergency room or hospital admission and the initial period of treatment. Failure to receive timely outpatient follow-up or discontinuities of care after an emergency room and/or hospital discharge can have tragic consequences; the elevated risk for death by suicide, suicide reattempts, and readmission during the post-discharge time period are well-documented as are the high rates of treatment non-adherence. The low level of follow-up care after discharge from the emergency room and hospital and during the initial phases of treatment underscores the need to improve care continuity of care during these critical high-risk time periods.
Introduction
Study Aims and Objectives
Childhood mental disorders are prevalent, disabling, and costly. An estimated 20% of youth (15 million) between the ages of 9 and 17 are diagnosed with a mental disorder, 9 to 13% (approximately 6 to 9 million) have significant functional impairments, and 5 to 9% have serious emotional disturbances--most commonly anxiety, mood, or disruptive behavior disorders.1-3 These conditions are often chronic, associated with significant functional impairments; family burden; poor health outcomes; co-morbidities, and serious mental illness in adulthood. 4-6 The risk of suicide is especially high for youths with depression:7 studies have shown that 60% of adolescent suicide victims had a depressive disorder at the time of death.8-10 The economic costs are also substantial: the U.S. spent nearly $12 billion on children's mental health services in 1998, according to the most recent national survey,11 and children with serious emotional disturbances constitute one-third of all high-cost users.12
Despite the high prevalence of childhood mental disorders, costs and availability of effective interventions, many youths receive inadequate treatment or no treatment at all.13, 14 The primary aim of this project was to assess patterns and quality of care received by children in Ohio’s public mental health system. Using existing statewide administrative Medicaid data, this project focused on two dimensions of quality: 1) effectiveness of care, the use of appropriate treatments that are consistent with evidence-based practice guidelines; and 2) accessibility, the ability to receive needed services. Project goals and objectives are consistent with national health priorities and broad aims as set forth by the Department of Health and Human Services to better care by making health care more accessible and to promote the use of best practices to enable healthy living. Specific objectives included:
(1) Develop quality measures for common childhood disorders
(2) Describe the quality of care for specific diagnostic groups
Background
Characteristics of Children with Serious Emotional Disturbances. Children and youth with serious emotional disturbances have complex needs often requiring comprehensive services of varying levels of intensity over extended periods of time and involvement with multiple providers and service systems.15 Many have multiple psychiatric disorders—disruptive behavioral disorders and mood disorders are the most highly prevalent--and experience significant functional impairments that interfere with their functioning at home, school, and with community activities; left untreated these youths are at risk for a number of adverse outcomes including substance abuse, suicide, school dropout, teen pregnancy, and incarceration.16,17 The burden of illness is also high, particularly for families 5 Because children with serious emotional disturbances use more services, they generate health care costs well beyond the majority of other mental health users; many of these youths are involved with the child welfare and juvenile justice system.18-21 Adolescents, males, and minority youths are overrepresented, as are youth from lower SES. 21
Barriers to Effective Care. Most youths with mental disorders do not receive any treatment, and the demand for children’s mental health services is expected to double by 2020. Epidemiological studies indicate that 75 to 80% of children between the ages of 6 to 17 with mental health disorders do not receive any mental health care, and rates of unmet need vary significantly by geographic region, ethnic group, and service sector.13,22 Across states, rates of unmet need range from as low as 51% to as high as 81%; these variations are likely related to differences in state policies and health care market characteristics.23 Across ethnic groups, minorities have the highest rates of unmet needs, with Latino children less likely to receive services for their mental health problems than any other ethnic group, despite higher rates of suicide.13, 24,25 Across systems of care, children and youths in the child welfare and juvenile justice system have the highest rates of unmet need--85% of these children do not receive services.19 Taken together, these findings underscore the need to improve access to care, particularly for low-income, minority, and rural populations.
Even when youths are able to access mental health services, quality of care is often poor. Empirically validated treatment exists for a number of major childhood conditions including: 1) ADHD;26 2) depression;27 3) anxiety disorders;28 and 4) conduct disorders.29 Over the past decade, there has also been a proliferation of clinical practice guidelines,30-32 quality indicators,33 and medication algorithms,34 all intended to improve quality of care by articulating evidence-based practices and by identifying the steps needed to implement optimal treatment. However, research has documented wide variations in quality of care including; a) failures to conform to evidence-based practice guidelines; b) underuse, overuse, and misuse of certain treatments; and c) racial and ethnic disparities in access and quality of care.14, 35
Why Focus on Quality of Care for Children in Medicaid? First, Medicaid is the largest financing program supporting children’s mental health services in the United States, contributing more than any other private or public source of funding.36 Second, children covered by Medicaid use more mental health services—outpatient, inpatient, and pharmacy-- than privately insured and uninsured children.37-39 Because they live in poverty and are exposed to multiple psychosocial stressors, they have more severe psychiatric illnesses that frequently require more intensive services. Third, children covered by Medicaid are more likely to receive poorer quality care and have worse health outcomes.40 For example, in a seven-state study, it was found that Medicaid covered youths are 4 times as likely as privately insured youth to receive antipsychotic medications.41