Disproportionately Increasing Psychiatric Visits to the Pediatric Emergency Department Among the Underinsured

Friday, October 14, 2011: 1:30 PM
Seaport Ballroom (Seaport Hotel)
Zachary E. Pittsenbarger, MD and Rebekah Mannix, MD, MPH, Emergency Medicine, Children's Hospital Boston, Boston, MA

Purpose: Recent studies have demonstrated that mental health visits are the fastest growing segment of the emergency medicine patient population and that emergency departments (ED) are increasingly serving as the safety net for medically underserved patients.  Prior investigations have shown an increasing frequency of pediatric mental health disorders in both primary care and emergency department settings.  To date, no study has looked at trends in pediatric psychiatric emergency department visits adjusting for socio-economic factors such as payer information, race and ethnicity to analyze if these groups have disproportionate increases in these visits.  Our goal was to describe the changes in ED psychiatric visits that occurred from 1999 through 2007 in the US pediatric population by socioeconomic and demographic group.

Methods: Publicly available ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1999 through 2007 were stratified by age, sex, race, ethnicity, insurance status and disposition.   We identified psychiatric visits using reason for visit codes. Underinsurance was defined as being self-pay or having Medicaid as the primary insurance.  Demographic data included age, gender, race, ethnicity, region, and metropolitan region.  Data were analyzed with appropriate weighting, to account for the survey sampling methodology, using the svy commands available in Stata/IC 11.1 (StataCorp, College Station, TX).  We performed trend tests using logistic regression analysis, and reported P values for each trend.

Results: Over the study period, 279 million pediatric patients were seen in US emergency departments of which 2.8% were for psychiatric visits.  The prevalence of psychiatric visits among pediatric patients increased from 2.4% (95% CI, 2,2.9) in 1999 to 3% (95% CI 2.5,3.5) in 2007 (p = 0.03 for trend).  The underinsured group increased from 46% (95% CI 38,55) of all pediatric psychiatric visits in 1999 to 54% (95% CI 46,62) in 2007 (p = 0.03 for trend). Rates of admission or transfer did not significantly increase for all pediatric psychiatric ED visits (p = 0.07) or for the underinsured (p = 0.19).  In multivariate analysis controlling for age, sex, race, region, and metropolitan statistical area; the odds of a psychiatric visit for underinsured pediatric patients increased by 3% each year (p = 0.03).

Conclusion:   Mental health related visits continue to be a significant reason for presentation to the emergency department in the pediatric population and have increased disproportionately in underinsured patients. These data suggest that emergency departments are increasingly serving as a safety net for patients with limited outpatient resources and other access to care.