Emergency Department Utilization Following Pediatric Psychiatric Hospitalization

Abstract

Objective:

ED utilization has increased disproportionately for pediatric psychiatric care. This study aimed to identify predictors of emergency department (ED) utilization within 30 days after discharge from a pediatric psychiatric hospitalization.

Methods:

ED utilization was assessed in the 30 days after discharge. Univariate logistic regression modeling identified predictors of ED utilization, which were used in subsequent multivariate modeling.

Results:

Greater number of trauma types (OR=1.92, CI=1.50–2.45, z=2.67, p=0.008), generalized anxiety disorder (OR=3.20, CI=1.78–5.76, z=1.98, p=0.048), and longer length of stay (OR=1.05, CI=1.03–1.07, z=2.74, p=0.006) were associated with increased ED utilization within 30 days of discharge.

Discussion:

ED utilization may be an important marker of negative outcomes within 30 days of discharge from pediatric psychiatric hospitalization. Patients with high trauma exposure, anxiety and acuity marked by increased LOS may require additional services to prevent unplanned ED utilization for psychiatric crises.

Background

Increased emergency department (ED) utilization and the negative effects of ED overcrowding are well documented.^1,2 The number of overall ED visits has increased significantly in recent years and the additional strain at a national level on ED resources, particularly staffing and space, has led to significant ED overcrowding and increases in wait time.³ ED utilization for psychiatric services is also significantly more costly.⁴ One contributor to the increased ED visits overall is the disproportionately large increase in children and adolescents presenting for psychiatric conditions.^5,6 Between 2001 and 2011, pediatric psychiatric ED visits increased from 4.2% to 7.2% of all pediatric ED visits.⁷ Unfortunately, causes of pediatric psychiatric ED utilization remain understudied, especially among high-risk clinical populations.

Patients discharged from a psychiatric hospitalization may be at especially high risk of ED utilization. The 30-day period immediately following discharge is a time of high risk and stress for these patients and their families. Patients are at elevated risk for a recurrence of suicidal thoughts or behaviors that often require immediate intervention in an emergency department.^8,9 To the best of our knowledge, no previous studies have explicitly examined clinical predictors of ED utilization during the critical period following a psychiatric hospitalization. Rather, previous research has focused on determining predictors of hospital readmission – a commonly used marker of negative outcomes adopted from the medical literature.

While psychiatric rehospitalization may frequently occur after hospitalization, it is not the only possible negative outcome. Due to logistical and economic factors, including referral policies, access to mental health services, lack of insurance, and requirements of insurance providers, the ED is the first and sometimes only line of support for many children needing mental health evaluation or stabilization.¹⁰ Therefore, examination of ED usage may more completely account for patients who require psychiatric services but are not rehospitalized, whether because of lack of need or lack of resources. To date, documentation of ED utilization as a discrete outcome after psychiatric hospitalization has been underexplored in the pediatric psychiatric literature.

This significant gap in the literature prevents identification of predictive risk factors for emergency care that could support the development of interventions to both improve outcomes for this population of patients during a critical high-risk period while also reducing the burden in the ED. To address this significant knowledge gap, this study aimed to identify demographic, clinical, and mental healthcare service predictors of ED utilization for a mental health evaluation within 30 days after hospital discharge, by prospectively following patients discharged from a pediatric psychiatric hospitalization.

Methods

This longitudinal, observational study was approved by the study site Institutional Review Board. Parents of children and adolescents discharged to the community from a Boston area acute inpatient psychiatric hospitalization program were recruited between June 15^th, 2014 and November 15^th, 2016 to participate in this study. All study participants provided written, informed consent. Clinical and demographic variables were collected from each patient’s electronic medical record. Parent/guardian reported 30-day ED usage was collected using REDCap, a secure electronic data capture system. At 30 days after discharge, parents/guardians were emailed a link to a secure electronic survey asking whether their child had an “assessment by a hospital emergency department for a mental health crisis” in the month since discharge from the study site. Between 33 and 45 days after discharge, if parents had not completed the survey, they were contacted with reminders to complete the survey first via email and then via phone.

Patient demographic variables included: age, sex, race, and adoption status. Clinical variables included reason for admission, discharge diagnosis, hospital LOS and type of planned outpatient treatment services (i.e., home with enrollment in a partial hospitalization program (PHP), or home with an appointment for outpatient therapy). The Brief Psychiatric Rating Scale for Children (BPRS-C) symptom domains were used to measure patient symptom severity on admission. A trauma exposure variable assessed how many types of trauma (physical abuse, sexual abuse, witness to violence, severe neglect, bullying, or traumatic loss) a patient had experienced prior to admission. All of the above variables were documented as part of the admission or discharge assessment for all children admitted to the unit by a licensed psychiatrist and were obtained from electronic medical records of intake and discharge summaries using a chart abstraction tool.

All statistical analyses were performed using R version 3.5.1. Observations with missing values were ignored. We first examined ED utilization and selected univariate predictors of ED utilization, using an alpha (α) level of 0.05, to include in a subsequent multivariate model. We then constructed a logistic regression model of clinical and demographic variables predicting ED utilization within 30 days of discharge.

Results

Of 242 enrolled parents, 155 (64%) reported whether or not their child had required an ED visit for a mental health crisis within the first 30 days following their hospital discharge. Patient characteristics did not significantly differ on any of the major demographic or clinical categories examined between the groups of parents who reported or did not report on the 30 day ED usage. Of the 155 patients whose parents did report, 116 (75%) were female, 115 (74%) were Caucasian, 8 (5%) were Asian, 7 (5%) were Hispanic, 5 (3%) were black, 9 (6%) identified as other, 17 (11%) did not document their ethnicity, 140 (90%) had a mood disorder diagnosis, and 140 (90%) had been hospitalized for risk of harm to self. The patient population had a median age of 15 years (range 7 to 18 years,) with a median hospital length of stay (LOS) of 11 days (range 1–52 days). Trauma exposure was documented on hospital admission, 63 patients (41%) experienced at least one trauma type, 20 (13%) experienced at least two trauma types, and 5 (3%) experienced three or more trauma types. Of the 155 patients with parent reported ED usage data, 24 (16%) utilized the ED for a mental health evaluation within 30 days of discharge. Of these 24 visits, 20 (83%) also had a psychiatric rehospitalization and four (17%) did not.

Supplemental Table 1 presents the results of all variables examined in this study in separate univariate logistic regression models. The three statistically significant univariate predictors of ED utilization included in the subsequent model building procedure included: total reported trauma types (OR=1.64, CI=1.30–2.06, z=2.16, p=0.031), hospital LOS (OR=1.04, CI=1.03–1.06, z=2.70, p=0.007), and a diagnosis of generalized anxiety disorder (GAD; OR=3.35, CI=2.02–5.56, z=2.40, p=0.028).

We constructed a multivariate logistic regression model using these selected predictor variables, which resulted in the final model in Table 1. In this multivariate model, each additional trauma type experienced (OR=1.92, CI=1.50–2.45, z=2.67, p=0.008), and each additional LOS day (OR=1.05, CI=1.03–1.07, z=2.74, p=0.006) and a GAD diagnosis (OR=3.20, CI=1.78–5.76, z=1.98, p=0.048) increased risk of ED utilization within 30 days of discharge when controlling for other predictors in the model. Also presented in Table 1 is a subsequent model controlling for ethnicity, age, sex and adoption status. In this model odds ratios remained comparable and p-values remained statistically significant for LOS, GAD, and trauma types.

Table 1.

Multivariate logistic regression final models predicting emergency department utilization

	Predictor Statistics						Model Statistics
	Odds Ratio	95% C.I.			Z	p-value	AIC	−2LL	AUC	df
Main effects model (n=141)							112.86	−52.42	0.72	137
Trauma	1.92	1.50	-	2.45	2.67	0.008
GAD	3.20	1.78	-	5.76	1.98	0.048
LOS	1.05	1.03	-	1.07	2.74	0.006
Intercept	0.04	0.02	-	0.07	−6.20	0.001
Adjusted main effects model (n=139)
Trauma	1.94	1.46	-	2.57	2.33	0.020	115.40	−49.70	0.74	131
GAD	3.62	1.97	-	6.63	2.12	0.034
LOS	1.05	1.03	-	1.07	2.56	0.011
Sex (ref = Male)	1.40	0.71	-	2.77	0.50	0.618
Caucasian (ref = Other ethnicities)	3.32	1.56	-	7.06	1.59	0.111
Age at admission	0.95	0.82	-	1.12	−0.30	0.767
Adoption Status	4.78	2.02	-	11.31	1.82	0.069
Intercept	0.02	0.00	-	0.23	−1.59	0.112

^*GAD = Generalized anxiety disorder; LOS = Length of stay; PHP = Partial hospitalization program (ref = Home)

In Online Appendix 1 we present findings of interaction effects between GAD and LOS and PHP utilization post discharge.

Discussion

Our study finds that patients with: 1) more lifetime documented trauma types; 2) a GAD diagnosis; and 3) longer LOS are at increased risk of utilizing the ED within 30 days of discharge. Below, we discuss each finding and its clinical implications.

Increased trauma type exposure is associated with increased ED utilization after a pediatric psychiatric hospitalization. These findings align with research that has found four or more co-occurring trauma types significantly increase the odds of self-harm, suicidal, or violent behaviors in a comparable inpatient population.¹¹ As a majority of patients (90%) are admitted to the study site due to risk of self-harm, complex trauma histories may increase ED utilization via increased levels of self-harm and suicidal behaviors.

In the final model, both a GAD diagnosis and longer hospital LOS were associated with increased risk of ED utilization when controlling for other variables. Our findings add to literature that implicates anxiety with increased healthcare utilization.¹² In our pediatric population, patients with GAD may be more likely to exhibit behaviors that result in caregivers seeking emergency care.

With regard to hospital LOS, other studies have reported longer LOS to be associated with increased risk of rehospitalization.¹³ We found in the final model that risk of ED utilization in the post-discharge study period increased as hospital LOS increased, while holding other model variables constant. Hospital LOS is a complex variable that may reflect patient acuity or greater psychosocial complexity during hospitalization. The supplemental analysis presented in Online Appendix 1 details preliminary findings that may elucidate one feature of this complexity, namely that LOS is associated with ED utilization risk differently for patients with GAD than patients without GAD.

The study findings suggest potential targets for improving patient outcomes following a pediatric psychiatric hospitalization, thereby decreasing the high use of ED services for a mental health evaluation for this high-risk population. Interestingly, not all patients who went to the ED for a mental health evaluation were hospitalized. Had rehospitalization been the outcome variable of interest, the negative outcomes for these patients would have been missed. To fully understand the outcomes of patients following a psychiatric hospitalization, researchers should consider collecting both variables in future longitudinal studies, especially in regions with significant differences in mental health care delivery and availability.

The current study has several limitations that should be addressed in future research. Given the absence of studies examining ED utilization following a pediatric psychiatric hospitalization, this study utilized a data-driven approach to identify predictors of ED utilization. Although this approach has the virtue of not excluding potential predictors in an underexplored area of outcomes research, it may increase type-1 error. Additionally, due to small sample size and single-site study design, the study findings may not generalize well to other populations. Considering these limitations, future research should aim to replicate these study findings in larger, multisite studies before applying findings to policy and practice. The current study also explored relatively few demographic variables, no ecological variables characterizing the child’s environment, used a basic measure of trauma. Future studies should more robustly control for socioeconomic status, characterize patients’ ecological environment, and measure trauma exposure.

Highlights.

• Pediatric psychiatric post-hospitalization outcomes research has focused almost exclusively on rehospitalization as an outcome, despite a significant uptick in pediatric psychiatric ED admissions and the resultant cost and burden.

• This study finds that a greater variety of trauma type exposure, generalized anxiety disorder, and longer LOS are associated with increased risk of ED utilization for a mental health evaluation in the 30 days after discharge to the community following pediatric psychiatric hospitalization.

• To reduce the cost and healthcare burden of this negative outcome, future research should seek to confirm these findings in larger multisite studies, and more directly control for underlying factors contributing to LOS, determination of discharge services and the child’s ecological context.