Some U.S. primary care practices manage far more patients who have mental health diagnoses than do others. The findings are detailed in a recently published study involving the AAP Pediatric Research in Office Settings (PROS) network (Mayne SL, et al. Pediatrics. 2016;137:e20152974, http://bit.ly/1TysYlz).
Prior research shows that some pediatricians are more comfortable than others in managing mental health diagnoses, and the demand for pediatricians to manage mental health diagnoses can vary by type of practice and region. This study digs more deeply to explore variation at the practice level, including the proportion of patients who have mental health diagnoses and patterns of prescribing psychotropic medications.
Data come from analyses of electronic health records (EHRs) from 294,748 children ages 4-18 years who received care between Jan. 1, 2009, and June 30, 2014, from 43 U.S. primary care practices. Forty-two percent were white, 19% black and 10% other; 29% had no race noted in the EHR. Two-thirds were ages 4-11 years, one-third were 12-18 years and half were female.
Researchers looked at whether any mental health diagnosis or psychotropic medication prescription was found at any time for a child during the five-year study period. Fifteen percent (nearly 41,000 children) had one or more mental health diagnoses; two-thirds of those had a diagnosis of ADHD. Fourteen percent (39,695 children) had received a prescription for at least one psychotropic medication. More than a third of children on any psychotropic medication had received medications from two or more drug classes, most commonly a mix of stimulants and α-agonists.
Data about patients’ diagnoses and receipt of psychotropic medications came from EHRs, and data about the practices came from pediatricians. Analyses were designed to describe the degree of variation across practices in the percentage of patients who had a mental health diagnosis and/or who were prescribed psychotropic medications. Researchers then looked for differences that might explain variation, such as whether a mental health professional was located in the same practice or nearby.
Results show the proportion of patients per practice who had a mental health diagnosis varied considerably from 2% to more than 20%. The proportion of patients who had a diagnosis of ADHD ranged from 1% to nearly 16%. Differences were smaller for anxiety, which ranged from less than 1% to nearly 8%; depression, which ranged from zero to almost 5%; and smaller still for autism, conduct disorder or oppositional disorder (all were 3% or less, yet still varied across practices).
The same was true for prescribing of psychotropic medications, which ranged from 4% to 25% of children per practice who were prescribed any psychotropic medication, and less than 1% to nearly 12% of those patients receiving prescriptions from two or more psychotropic medication classes. Stimulant prescribing varied the most, ranging from 3% to 19% of children within a practice receiving prescriptions for stimulant medications (see figure).
Pediatricians’ perceptions of access to psychiatrists in their community explained part of the variation in diagnosis and prescribing across practices. However, the co-location of mental health services in primary care practices did not contribute to variability in either diagnosis or prescribing. Practices with mental health services on site neither treated fewer patients with mental health diagnoses nor prescribed psychotropic medications less frequently.
The results of this study highlight the need for greater understanding of reasons for variability and the implications for pediatricians, children and families.
This study involved collaboration among pediatric practices from the AAP PROS Network and The Children’s Hospital of Philadelphia (CHOP) PeRC network as well as researchers from CHOP, University of Pennsylvania, University of Vermont and the Academy.
The project was supported in part by the U.S. Department of Health and Human Services (HHS) with the National Institutes of Child Health and Human Development under grants R40MC24943, UB5MC20286 and UA6MC15585; CHOP and the Academy. This content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HHS or the U.S. Government.
