MHW: Study Finds Higher MH Readmission Rates for Children

Study Finds Readmissions Rates Higher After MH Admission
Mental Health Weekly December 4, 2017

Readmission rates were higher for children after mental health admissions than after non–mental health admissions, according to researchers at Boston’s Children’s Hospital in the first large cohort study focusing on pediatric mental health patients. The study was published Nov. 29 in Pediatrics, the journal of the American Academy of Pediatrics.

This is the first study involving pediatric readmission to be conducted on this scale, said Sara L. Toomey, M.D., MPhil, MPH, MSc, director of the Center of Excellence for Pediatric Quality Measurement at Boston Children’s Hospital, chief experience officer, Division of General Pediatrics, Boston Children’s Hospital/Harvard Medical School. Smaller studies have focused on one hospital or one health system; however, the current study is the first to examine this question from a multistate perspective, Toomey, study co-author, told MHW.

Reducing readmissions is a major health care system goal, researchers noted. “There is a gap in our understanding of pediatric readmission patterns after mental health admissions,” they wrote. With this study, researchers aimed to characterize the prevalence of readmissions after mental health admissions, to identify patient-level factors and costs associated with readmissions, and to assess variation in readmission rates across hospitals.

Psychiatric care constitutes a substantial and growing proportion of pediatric inpatient care use, accounting for 10 percent of all pediatric admissions and $3.3 billion in aggregate charges in 2014, the study stated. In the last two decades, mood disorders alone have overtaken asthma as the most common reason for admission among children aged 1 to 17 years, with a 68 percent increase in the rate of mood disorder hospitalizations despite a 26 percent decrease in the overall hospitalization rate for the age group.

The Center of Excellence for Pediatric Quality Measurement at Boston Children’s Hospital, where the research was conducted, was created as one of the seven Centers of Excellence initially funded through the national Pediatric Quality Measures Program by the Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services, explained Jeremy Y. Feng, AB, co-author of the study.

“As a Center of Excellence, our purpose was to increase the portfolio of evidence-based, consensus- approved pediatric quality measures available to public and private payers, providers and consumers,” Feng told MHW.

Study methods
Researchers used the 2014 Healthcare Cost and Utilization Project all-payer Nationwide Readmissions Database, and conducted a retrospective cohort analysis of 253,309 admissions for 5- to 17-year- olds at acute-care hospitals in 22 states. They calculated 30-day unplanned readmission rates, lengths of stay and costs by primary admission diagnosis.

Researchers also used hierarchical regression models to assess differences in readmission rates by patient characteristics, primary diagnoses and comorbid chronic conditions, and to estimate the variation in case mix–adjusted rates across hospitals.

They defined readmission as the first unplanned admission within 30 days of an index admission. Any subsequent admissions that occurred within 30 days were not counted as either readmissions or new index admissions.

Mental health admissions are very common, accounting for 19 percent of all pediatric admissions, said Toomey. Thirty-day readmission rates were higher after mental health admissions than after non–mental health admissions (8 percent vs. 6.2 percent), she said.

There was considerable variation around hospital-level readmission rates for mental health, said Toomey. “That’s a signal for us that with that variation, hospitals have room to improve,” she said.

Children who were under 14 years old, had non–mental health chronic conditions and/or had public insurance were more likely to be readmitted than their peers, the study found. On average, children readmitted after MH admissions were hospitalized for more than a week.

Toomey noted that she and her colleagues cannot explain the reasons for readmissions in this cross-sectional study that utilized large secondary data. Other studies, however, would suggest one factor for the increased readmission rates would be that pediatric mental health is hard to manage in an outpatient setting, she said. “Often there is a lack of adequate outpatient pediatric mental health care,” Toomey said.

She added that therapies and services are not often accessible, she said. “Studies have shown that many areas around the country have fewer pediatric psychiatric services and providers than are necessary for the level of children with mental health conditions,” said Toomey.

Toomey added that having an understanding of how difficult provider adequacy and mental health outpatient services and knowing how severe many children’s mental health conditions are, she wasn’t overly surprised by the fact that readmission rates would be higher than general admission rates for medical conditions. However, some medical conditions do have higher readmission rates, she added.

Toomey cited one example of the state’s plan to improve inpatient and outpatient care for children with mental health conditions. The state’s Medicaid program, MassHealth, has plans to create an accountable care organization program that emphasizes partnerships with community-based providers, said Toomey. Improving care for those with mental health conditions is a major focus, she added.

“Community mental health services are going to be vital to provide pediatric patients with mental health conditions the services they need,” said Toomey.