For kids seeking emergency department (ED) care for mental health conditions, the risk for prolonged length of stay (LOS) is getting worse, researchers found — and kids of Hispanic ethnicity were at the highest risk.
As the rate of children using the ED for mental health needs increases, the risk of spending too much time in the ED — and consequently missing out on definitive mental health care — becomes more apparent, Katherine A. Nash, MD, of the National Clinician Scholars Program and the Department of Pediatrics at Yale University in New Haven, Connecticut, and colleagues explained in Pediatrics. Not only can prolonged LOS lead to additional mental health strains due to loud noises, frequent changes in health care providers, and security presence, but it also leads to general ED crowding, “rendering other patients at risk for delays, decreased quality of care, and leaving the ED without being seen by a provider.”
What’s more, children who are from racial/ethnic minorities, living in poverty and/or publicly uninsured, or who are without a concurrent mental health diagnosis might face a heightened risk for prolonged LOS, they added.
In order to quantify the impact of prolonged LOS for kids with mental health conditions, Nash and colleagues examined over a decade of national, temporal trends in ED LOS to compare pediatric mental health visits with non-mental health visits and to examine whether demographic and clinical characteristics were associated with prolonged LOS.
“Over the 11-year study period, the odds of prolonged LOS for mental health ED visits were threefold greater and increased over time compared with non–mental health ED visits, which remained stable,” they found. “Compared with white non-Hispanic children, Hispanic children had an increased risk of prolonged ED LOS. There was no difference in ED LOS by payer type. Additionally, the odds of prolonged ED LOS for visits with only mental health diagnoses increased over time in comparison with visits with both mental and physical health diagnoses.”
The substantial rise in LOS over the study period and disparity for Hispanic children suggests “worsening and inequitable access to definitive pediatric mental health care,” Nash and colleagues wrote, calling on policy makers and health systems to work to “provide equitable and timely access to pediatric mental health care.”
Polinas Krass, MD, and Stephanie K. Doupnik, MD, MSHP, both of the PolicyLab and Department of Pediatrics at the Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, writing in an editorial accompanying the study, agreed that institutions would likely benefit from interventions designed to improve the quality of mental health services — and, they added, the Covid-19 pandemic may have exacerbated some of these issues.
“Increases in frequency and severity of mental illness are compounded by disruptions in nonessential health care access and increased risks associated with being in a crowded ED or an inpatient psychiatric unit,” they wrote. “Black and Hispanic families have borne an undue burden of grief, financial instability, and educational disruption because of the pandemic and may suffer worse mental health outcomes as well.”
Krass and Doupnik acknowledged that policies such as the recent American Rescue Plan Act (March 10, 2021) may help to alleviate these impacts through more robust funding to institutions that may assist in expanding mental health crisis services. However, they argued, some youth will still require stabilization in an ED.
“For these patients, the highest-quality ED mental health services would expand beyond triage, assessment, and safety observation,” they wrote. “Billing and reimbursement strategies that incentivize the provision of mental health care by ED providers, including safety planning, lethal-means reduction, and postdischarge mental health outreach, would enable more children to receive evidence-based mental health treatments more quickly.”
For this observational analysis, Nash and colleagues looked at data from ED visits among children 6-17 years of age using the National Hospital Ambulatory Medical Care Survey (NHAMCS
The primary outcome was prolonged ED LOS, for which they examined three definitions: >6 hours (consistent with most studies examining mental health ED visits), >12 hours, and >24 hours. They also examined the association between prolonged ED LOS and demographic/clinical characteristics, including race/ethnicity, payer type (private, public, other), and presence of a concurrent physical health diagnosis.
Across the board, mental health ED visits had higher rates of prolonged LOS than non-mental health visits: 21.2% versus 4.8% for >6 hours, 7.7% versus 1.2% for >12 hours, and 1.9% versus 0.3% for >24 hours.
“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,” Nash and colleagues found. “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.”
The study authors noted that, while a higher percentage of mental health ED visits resulted in admission or transfer compared with non-mental health visits, “the proportion of mental health visits resulting in admission or transfer did not change over time and thus cannot explain increasing rates of prolonged ED LOS for these visits… Concurrent with an increasing incidence of mental health conditions, over the past half century, the number of inpatient psychiatric beds has declined without compensatory expansion of outpatient services. Mental health care for children is expensive, and suboptimal reimbursement limits incentives to expand services. There continues to be a dearth of child psychiatrists and community supports. EDs struggle to safely discharge children who present in crisis to appropriate care settings in light of limited services and poor coverage, which in turn leads to prolonged ED LOS.”
Study limitations included that the NHAMCS collects data at the visit and not at the patient level, preventing the study authors from assessing the impact of repeat visits; sample size constraints and limited quality of discharge diagnosis data; and that the NHAMCS does not provide hospital location data beyond region.
Rates of prolonged emergency department length of stay (ED LOS) increased dramatically from 2005-2015 for pediatric mental health visits compared to non-mental health visits, and the risk for prolonged LOS was three times higher for Hispanic children.
These findings suggest worsening and inequitable access to definitive pediatric mental health care in the U.S.
John McKenna, Associate Editor, BreakingMED™
The study was funded by the National Clinician Scholars Program and the Clinical and Translational Science Award grant TL1 TR001864 from the National Center for Advancing Translational Science, a component of the National Institutes of Health (NIH).
The study authors had no relevant relationships to disclose.
The editorial authors had no relevant relationships to disclose.
Cat ID: 138
Topic ID: 85,138,254,791,730,138,192,146,925