Who Comes Back? Characteristics and Predictors of Return to Emergency Department Services for Pediatric Mental Health Care

Abstract

Objectives: The objective of this study was to investigate predictors of emergency department (ED) return visits for pediatric mental health care. The authors hypothesized that through the identification of clinical and health system variables that predict return ED visits, which children and adolescents would benefit from targeted interventions for persistent mental health needs could be determined.Methods: Data on 16,154 presentations by 12,589 pediatric patients (£17 years old) were examined from 2002 to 2006, using the Ambulatory Care Classification System (ACCS), a provincewide database for Alberta, Canada. Multivariable logistic regressions identified predictors, while survival analyses estimated time to ED return. Results:In the multivariable analysis, there were four patient factors significantly associated with ED return. Male sex (odds ratio [OR] = 0.78; 99% confidence interval [CI] = 0.69 to 0.89) was associated with a lower rate of return, as was child age. The likelihood of ED return increased with age. Children £5 years (OR = 0.26; 99% CI = 0.14 to 0.46) and between ages 6 and 12 (OR = 0.64; 99% CI = 0.51 to 0.79) were less likely to return, compared to 13-to 17-year-olds. Patients with families receiving full assistance for covering government health care premiums were more likely to return compared to those with no assistance (OR = 1.59; 99% CI = 1.33 to 1.91). Patients were more likely to return if their initial presentation was for a mood disorder (OR = 1.72; 99% CI = 1.46 to 2.01) or psychotic-related illness (OR = 2.53; 99% CI = 1.80 to 3.56). There were two modest health care system predictors in the model. The likelihood of return decreased for patients triaged as nonurgent (OR = 0.62; 99% CI = 0.45 to 0.87) versus those triaged as urgent (level 3 acuity) and increased for patients with visits to general (vs. pediatric) EDs (OR = 1.25; 99% CI = 1.03 to 1.52). ED region (urban vs. rural) did not predict return. Within 72 hours of discharge, 6.1 and 8.7% of patients diagnosed with a mood disorder and psychotic-related illness, respectively, returned to the ED. Throughout the study period, 28.5 and 36.6% of these diagnostic populations, respectively, returned to the ED.Conclusions: Among children and adolescents who accessed the ED for mental health concerns, being female, older in age, in receipt of social assistance, and having an initial visit for a mood disorder or psychotic-related illness were associated with return for further care. How patient presentations were triaged and whether visits were made to a pediatric or general ED also affected the likelihood of return.

Trends in Pediatric Visits to the Emergency Department for Psychiatric Illnesses

“…We decided a priori to include age, sex, race, ethnicity, region, urban status, and year in the model, as they have been previously demonstrated to be associated with differences in both ED and psychiatric care. 3,6,7,11,12,16,[19][20][21][22][23][24] For the length of stay (LOS) analysis as our secondary outcome, we tested for trend the median visit length. Median LOS is used in place of the mean LOS as values were not normally distributed.…”

“…9,10 Outpatient access to psychiatric care for children may be limited, especially in certain at-risk socioeconomic groups. 6,[11][12][13][14] While the PECARN study and several Canadian studies have suggested that socioeconomic factors may be associated with high odds of ED psychiatric visits, 3,12,[15][16][17] no study has evaluated these factors using nationally representative United States data. The specific focus of this study was on sociodemographic factors and their effect on odds of ED visits.…”

Predictors of Repeated Visits to a Pediatric Emergency Department Crisis Intervention Program

“…7,13 Repeat presentations represent a large proportion of PED MH presentations with estimates ranging from 12% to 36%. [14][15][16] This may be the result of a lack of availability or difficulty accessing MH services that effectively meet this patient population's needs. 14,17 Findings on predictors of repeat PED for MH issues are inconsistent.…”

Space and time clustering of adolescents’ emergency department use and post-visit physician care for mood disorders in Alberta, Canada: A population-based 9-year retrospective study

“…7 More recent Alberta-based research has suggested that mood-based crises are among the most frequent reasons for pediatric mental health emergency department (ED) visits. 8 A related study reported adolescents aged 13 to 17 were 1.5 times more likely to return for subsequent ED care compared to 6 to 12 year olds, 9 and that within 72 hours of ED discharge, 6% of children and adolescents diagnosed with a mood disorder will return for further acute care. 9 Combined, this body of Canadian literature suggests that Canadian adolescents are engaging a pattern of acute mental health services use with little to no receipt of community-based or primary care health care.…”

“…8 A related study reported adolescents aged 13 to 17 were 1.5 times more likely to return for subsequent ED care compared to 6 to 12 year olds, 9 and that within 72 hours of ED discharge, 6% of children and adolescents diagnosed with a mood disorder will return for further acute care. 9 Combined, this body of Canadian literature suggests that Canadian adolescents are engaging a pattern of acute mental health services use with little to no receipt of community-based or primary care health care. Large, national efforts to improve access to and receipt of mental health services in childhood and adolescence are ongoing (e.g., Mental Health Commission of Canada surveillance techniques in Canada's health databases as a practical and cost-effective strategy to reveal patterns of mental health resource use and inform health resource planning.…”