Variations in Mental Health Diagnosis and Prescribing Across Pediatric Primary Care Practices

Abstract

BACKGROUND: Primary care pediatricians increasingly care for children’s mental health problems, but little is known about practice-level variation in diagnosis and psychotropic medication prescribing practices. METHODS: This retrospective review of electronic heath records from 43 US primary care practices included children aged 4 to 18 years with ≥1 office visit from January 1, 2009, to June 30, 2014. We examined variability in diagnosis and psychotropic prescribing across practices using logistic regression with practice fixed effects and evaluated associations of the availability of colocated or community-based mental health providers or the proportion of children in foster care with diagnosis and prescribing using generalized linear mixed models. RESULTS: Among 294 748 children, 40 932 (15%) received a mental health diagnosis and 39 695 (14%) were prescribed psychotropic medication. Attention deficit/hyperactivity disorder was most commonly diagnosed (1%–16% per practice). The proportion of children receiving any psychotropic medication (4%-26%) and the proportion receiving ≥2 medication classes (1%-12%) varied across practices. Prescribing of specific medication classes also varied (stimulants, 3%–18%; antidepressants, 1%–12%; α-agonists, 0%–8%; second-generation antipsychotics, 0%–5%). Variability was partially explained by community availability of psychiatrists (significantly higher odds of a diagnosis or prescription when not available) but not by colocation of mental health professionals or percentage of children in foster care. CONCLUSIONS: The prevalence of mental health diagnosis and psychotropic medication prescribing varies substantially across practices and is only partially explained by psychiatrist availability. Research is needed to better define the causes of variable practice-level diagnosis and prescribing and implications for child mental health outcomes.

Comorbidity of attention deficit hyperactivity disorder and type 1 diabetes in children and adolescents: Analysis based on the multicentre DPV registry

“…In this multicentre analysis it was difficult to standardize the diagnosis of psychiatric disorders like ADHD, especially for patients without stimulant therapy. A consistent diagnosis of ADHD is challenging, as demonstrated by regional differences of ADHD prevalence . The DPV database is focussed on diabetes, therefore we were not able to provide details on psychological testing, on stimulant dosage or on adherence to pharmacological and non‐pharmacological therapy.…”

Diagnostic Errors in Primary Care Pediatrics: Project RedDE

“…Almost 70% of our practices were university affiliated and 40% had already worked “a lot” on one of these errors. An electronic health record study of depression diagnoses in pediatric primary care suggested only 2.1% of adolescents carried a diagnosis of depression, 32 while the comprehensive 2014 National Survey on Drug Use and Health suggested this incidence is 11.4%. 16 Our group of practices presented a frequency of 6.3%, higher than the electronic health record study, but still leaving potentially at least one out of every three depressed adolescents unrecognized.…”

“…12–16 Research also suggests that many adolescent depression cases are missed by primary providers suggesting under-diagnoses are vastly more of a problem than over diagnoses. 17,31,32 We first considered using documented depressive symptoms (e.g. poor school performance, interrupted sleep patterns, increased disruptive behaviors, etc.)…”

Visualizing nationwide variation in Medicare Part D prescribing patterns

“…We identified a skewed distribution in provider claims volume and drug prescribing diversity, with most participating providers making relatively few claims of a small number of drug types. Previously, a number of focused studies have examined prescription diversity, mostly with respect to opioid analgesics [52][53][54][55][56][57][58], antibiotics [1,[59][60][61][62][63], psychiatric medications [64][65][66][67], and among general practitioners [31,[68][69][70][71][72]. One web site has made the Medicare Part D prescribing data searchable with varios filters for provider, charges, and medications [73][74][75].…”