Publications by authors named "Bonnie T Zima"

70 Publications

Prolonged Emergency Department Length of Stay for US Pediatric Mental Health Visits (2005-2015).

Pediatrics 2021 Apr 5. Epub 2021 Apr 5.

Emergency Medicine, and.

Background And Objectives: Children seeking care in the emergency department (ED) for mental health conditions are at risk for prolonged length of stay (LOS). A more contemporary description of trends and visit characteristics associated with prolonged ED LOS at the national level is lacking in the literature. Our objectives were to (1) compare LOS trends for pediatric mental health versus non-mental health ED visits and (2) explore patient-level characteristics associated with prolonged LOS for mental health ED visits.

Methods: We conducted an observational analysis of ED visits among children 6 to 17 years of age using the National Hospital Ambulatory Medical Care Survey (2005-2015). We assessed trends in rates of prolonged LOS and the association between prolonged LOS and demographic and clinical characteristics (race and ethnicity, payer type, and presence of a concurrent physical health diagnosis) using descriptive statistics and survey-weighted logistic regression.

Results: From 2005 to 2015, rates of prolonged LOS for pediatric mental health ED visits increased over time from 16.3% to 24.6% (LOS >6 hours) and 5.3% to 12.7% (LOS >12 hours), in contrast to non-mental health visits for which LOS remained stable. For mental health visits, Hispanic ethnicity was associated with an almost threefold odds of LOS >12 hours (odds ratio 2.74; 95% confidence interval 1.69-4.44); there was no difference in LOS by payer type.

Conclusions: The substantial rise in prolonged LOS for mental health ED visits and disparity for Hispanic children suggest worsening and inequitable access to definitive pediatric mental health care. Policy makers and health systems should work to provide equitable and timely access to pediatric mental health care.
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http://dx.doi.org/10.1542/peds.2020-030692DOI Listing
April 2021

Editorial: The Cost of Comorbid Child Psychiatric Disorders: A National Call to Achieve the Triple Aim for Child Mental Health Care.

Authors:
Bonnie T Zima

J Am Acad Child Adolesc Psychiatry 2021 Mar 10;60(3):336-337. Epub 2020 Dec 10.

UCLA-Semel Institute for Neuroscience and Human Behavior, Los Angeles, California. Electronic address:

The National Quality Strategy to transform the US health care system is predicated upon Donald Berwick et al.'s "Triple Aim" envisioning the simultaneous pursuit of improved care, better population health, and reduced costs. More recently, emphasis has been placed on improving the value of health care as defined by "achieving the best patient health outcomes (quality + experience) at the lowest cost." US health care expenditures are projected to grow at an average annual rate of 5.4% during this decade, reaching 19.7% of the gross domestic product or an estimated 6.1 billion dollars by 2028. Compared with 36 high-income countries, including Canada, the US spends nearly twice as much on health care yet has the lowest life expectancy and highest suicide rate. However, solely targeting reduction in mental health care costs is not a solution, because the mental and general health care systems are inextricably linked and for children span multiple care sectors (eg, schools, child welfare, juvenile justice). In this issue of the Journal, Ansari et al. validates the complexity of physically ill children with a comorbid psychiatric disorder among more than 50,000 admissions to an acute-care pediatric specialty hospital within Canada's publicly funded health care system. Almost one out of 10 admissions for a physical illness had a documented comorbid psychiatric disorder, which is consistent with US pediatric hospital discharges. Children who were older, more clinically complex, and with prior hospitalizations were more likely to be among inpatient admissions with a comorbid psychiatric disorder. With outstanding methodologic rigor, the data suggest that pediatric inpatient admissions with comorbid psychiatric disorders had a nearly 10% longer length of stay and higher costs per admission compared with inpatient admissions without a comorbid psychiatric disorder---a difference in total cumulative costs of more than CAN$11.3 million (equivalent of about US$8.4 million).
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http://dx.doi.org/10.1016/j.jaac.2020.12.004DOI Listing
March 2021

Leveraging Clinical Informatics to Improve Child Mental Health Care.

J Am Acad Child Adolesc Psychiatry 2020 12;59(12):1314-1317

UCLA Semel Institute for Neurosciences and Human Behavior, Los Angeles, California.

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http://dx.doi.org/10.1016/j.jaac.2020.06.014DOI Listing
December 2020

Measurement-based Data to Monitor Quality: Why Specification at the Population Level Matter?

Authors:
Bonnie T Zima

Child Adolesc Psychiatr Clin N Am 2020 10 29;29(4):703-731. Epub 2020 Jul 29.

UCLA-Semel Institute for Neurosciences and Human Behavior, University of California at Los Angeles, UCLA Center for Health Services & Society, 10920 Wilshire Boulevard #300, Los Angeles, CA 90024, USA. Electronic address:

Measurement-based care is conceptualized as a driver for quality improvement. The triple aim in the National Quality Strategy purposively muddles the population levels to provide a health policy goal that is encompassing, transactional, and will stimulate change. Specification of the population level has implications for the purpose, proposed target mechanisms that drive quality improvement, methodologic challenges, and implications for program evaluation and data interpretation. To demonstrate, population levels are conceptualized at the individual (tier 1), clinical aggregate (tier 2), and national level (tier 3).
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http://dx.doi.org/10.1016/j.chc.2020.06.008DOI Listing
October 2020

Measures of ED utilization in a national cohort of children.

Am J Manag Care 2020 06;26(6):267-272

Department of Pediatrics, Medical University of South Carolina, 135 Rutledge Ave, MSC 561, Charleston, SC 29425. Email:

Objectives: Emergency department (ED) utilization is often used as an indicator of poor chronic disease control and/or poor quality of care. We sought to determine if 2 ED utilization measures identify clinically or demographically different populations of children.

Study Design: Retrospective cohort study utilizing IBM Health/Truven MarketScan Medicaid data.

Methods: Children and adolescents were categorized based on the presence and complexity of chronic medical conditions using the 3M Clinical Risk Group system. Children and adolescents were categorized as high ED utilizers using 2 measures: (1) ED reliance (EDR) (number of ED visits / [number of ED visits + number of ambulatory visits]; EDR >0.33 = high utilizer) and (2) visit counts (≥3 ED visits = high utilizer). Logistic regression models identified patient factors associated with each of our outcome measures.

Results: A total of 5,438,541 children and adolescents were included; 65% were without chronic disease (WO-CD), 32% had noncomplex chronic disease (NC-CD), and 3% had complex chronic disease (C-CD). EDR identified 18% as frequent utilizers compared with 7% by the visit count measure. In the visit count model, children younger than 2 years and those classified as WO-CD and NC-CD were less likely to be identified as high utilizers. Conversely, in the EDR model, children and adolescents 2 years and older and those classified as WO-CD and NC-CD were more likely to be classified as high utilizers.

Conclusions: The ED utilization measures identify clinically and demographically different groups of patients. Future studies should consider the medical complexity of the population being studied before choosing the most appropriate measure to employ.
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http://dx.doi.org/10.37765/ajmc.2020.43490DOI Listing
June 2020

The Impact of Attachment-Disrupting Adverse Childhood Experiences on Child Behavioral Health.

J Pediatr 2020 06;221:224-229

Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA.

Objectives: To describe patterns of overall, within-household, and community adverse childhood experiences (ACEs) among children in vulnerable neighborhoods and to identify which individual ACEs, over and above overall ACE level, predict need for behavioral health services.

Study Design: This was a cross-sectional study that used a sample of 257 children ages 3-16 years who were seeking primary care services with co-located mental healthcare services at 1 of 2 clinics in Chicago, Illinois. The outcome variable was need for behavioral health services (Pediatric Symptom Checklist score ≥28). The independent variables were ACEs, measured with an adapted, 28-item version of the Traumatic Events Screening Inventory.

Results: Six ACE items were individually predictive of a clinical-range Pediatric Symptom Checklist score after adjusting for sociodemographic covariates: emotional abuse or neglect (OR 2.93, 95% CI 1.32-6.52, P < .01), natural disaster (OR 3.89, 95% CI 1.18-12.76, P = .02), forced separation from a parent or caregiver (OR 2.95, 95% CI 1.50-5.83, P < .01), incarceration of a family member (OR 2.43, 95% CI 1.20-4.93, P = .01), physical attack (OR 2.84, 95% CI 1.32-6.11, P < .01), and community violence (OR 2.35, 95% CI 1.18-4.65, P = .01). After adjusting for overall ACE level, only 1 item remained statistically significant: forced separation from a parent or caregiver (OR 2.44, 95% CI 1.19-5.01, P = .02).

Conclusions: ACEs that disrupt attachment relationships between children and their caregivers are a significant predictor of risk for child emotional or behavioral problems.
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http://dx.doi.org/10.1016/j.jpeds.2020.03.006DOI Listing
June 2020

ED Visits and Readmissions After Follow-up for Mental Health Hospitalization.

Pediatrics 2020 06 13;145(6). Epub 2020 May 13.

Department of Pediatrics, School of Medicine, University of Washington and Seattle Children's Research Institute, Seattle, Washington.

Objectives: A national quality measure in the Child Core Set is used to assess whether pediatric patients hospitalized for a mental illness receive timely follow-up care. In this study, we examine the relationship between adherence to the quality measure and repeat use of the emergency department (ED) or repeat hospitalization for a primary mental health condition.

Methods: We used the Truven MarketScan Medicaid Database 2015-2016, identifying hospitalizations with a primary diagnosis of depression, bipolar disorder, psychosis, or anxiety for patients aged 6 to 17 years. Primary predictors were outpatient follow-up visits within 7 and 30 days. The primary outcome was time to subsequent mental health-related ED visit or hospitalization. We conducted bivariate and multivariate analyses using Cox proportional hazard models to assess relationships between predictors and outcome.

Results: Of 22 844 hospitalizations, 62.0% had 7-day follow-up, and 82.3% had 30-day follow-up. Subsequent acute use was common, with 22.4% having an ED or hospital admission within 30 days and 54.8% within 6 months. Decreased likelihood of follow-up was associated with non-Hispanic or non-Latino black race and/or ethnicity, fee-for-service insurance, having no comorbidities, discharge from a medical or surgical unit, and suicide attempt. Timely outpatient follow-up was associated with increased subsequent acute care use (hazard ratio [95% confidence interval]: 7 days: 1.20 [1.16-1.25]; 30 days: 1.31 [1.25-1.37]). These associations remained after adjusting for severity indicators.

Conclusions: Although more than half of patients received follow-up within 7 days, variations across patient population suggest that care improvements are needed. The increased hazard of subsequent use indicates the complexity of treating these patients and points to potential opportunities to intervene at follow-up visits.
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http://dx.doi.org/10.1542/peds.2019-2872DOI Listing
June 2020

U.S. Child Behavioral Health Quality Measures: Advancing a National Research Agenda.

Authors:
Bonnie T Zima

J Abnorm Child Psychol 2020 06;48(6):745-756

UCLA-Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA.

This paper is based on the keynote presentation for the biennial meeting of the International Society for Research on Child and Adolescent Psychopathology (ISRCAP) in Los Angeles, California. The topic was purposively selected to raise awareness of how the measurement of child behavioral health care quality at the national level, and corresponding standards for reliability and clinical validity, substantially differ from those traditionally applied to the measurement of child psychopathology. Under a federal mandate, an initial Core Set of quality measures for children was created for voluntary reporting by State Medicaid agencies. The four national child behavioral health quality measures in the 2019 Child Core Set encompass timeliness of care, vary by child age range, and two different types of psychotropic medication treatments. Measures are described and implications for data interpretation are provided. Findings are summarized from: 1) a systematic literature review; 2) State adherence rates; and 3) ten-year national trends in adherence rates by health plan type. Scientific evidence supporting the clinical validity of the measures is scarce, statewide adherence rates widely vary, and improvement over time has been modest. Nevertheless, State Medicaid agencies will be mandated to report measure adherence rates beginning in 2024. Together, these findings stimulate recommendations for health policies to allocate additional resources for data infrastructure to monitor child mental health care quality and identify areas for future research.
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http://dx.doi.org/10.1007/s10802-020-00640-9DOI Listing
June 2020

Health Care Utilization and Spending for Children With Mental Health Conditions in Medicaid.

Acad Pediatr 2020 07 2;20(5):678-686. Epub 2020 Feb 2.

Division of General Pediatrics, Department of Medicine, Complex Care Service, Boston Children's Hospital, Harvard Medical School (JG Berry), Boston, Mass.

Objective: To examine how characteristics vary between children with any mental health (MH) diagnosis who have typical spending and the highest spending; to identify independent predictors of highest spending; and to examine drivers of spending groups.

Methods: This retrospective analysis utilized 2016 Medicaid claims from 11 states and included 775,945 children ages 3 to 17 years with any MH diagnosis and at least 11 months of continuous coverage. We compared demographic characteristics and Medicaid expenditures based on total health care spending: the top 1% (highest-spending) and remaining 99% (typical-spending). We used chi-squared tests to compare the 2 groups and adjusted logistic regression to identify independent predictors of being in the top 1% highest-spending group.

Results: Children with MH conditions accounted for 55% of Medicaid spending among 3- to 17-year olds. Patients in the highest-spending group were more likely to be older, have multiple MH conditions, and have complex chronic physical health conditions (P <.001). The highest-spending group had $164,003 per-member-per-year (PMPY) in total health care spending, compared to $6097 PMPY in the typical-spending group. Ambulatory MH services contributed the largest proportion (40%) of expenditures ($2455 PMPY) in the typical-spending group; general health hospitalizations contributed the largest proportion (36%) of expenditures ($58,363 PMPY) in the highest-spending group.

Conclusions: Among children with MH conditions, mental and physical health comorbidities were common and spending for general health care outpaced spending for MH care. Future research and quality initiatives should focus on integrating MH and physical health care services and investigate whether current spending on MH services supports high-quality MH care.
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http://dx.doi.org/10.1016/j.acap.2020.01.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340572PMC
July 2020

Receipt of Addiction Treatment After Opioid Overdose Among Medicaid-Enrolled Adolescents and Young Adults.

JAMA Pediatr 2020 03 2;174(3):e195183. Epub 2020 Mar 2.

Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts.

Importance: Nonfatal opioid overdose may be a critical touch point when youths who have never received a diagnosis of opioid use disorder can be engaged in treatment. However, the extent to which youths (adolescents and young adults) receive timely evidence-based treatment following opioid overdose is unknown.

Objective: To identify characteristics of youths who experience nonfatal overdose with heroin or other opioids and to assess the percentage of youths receiving timely evidence-based treatment.

Design, Setting, And Participants: This retrospective cohort study used the 2009-2015 Truven-IBM Watson Health MarketScan Medicaid claims database from 16 deidentified states representing all US census regions. Data from 4 039 216 Medicaid-enrolled youths aged 13 to 22 years were included and were analyzed from April 20, 2018, to March 21, 2019.

Exposures: Nonfatal incident and recurrent opioid overdoses involving heroin or other opioids.

Main Outcomes And Measures: Receipt of timely addiction treatment (defined as a claim for behavioral health services, for buprenorphine, methadone, or naltrexone prescription or administration, or for both behavioral health services and pharmacotherapy within 30 days of incident overdose). Sociodemographic and clinical characteristics associated with receipt of timely treatment as well as with incident and recurrent overdoses were also identified.

Results: Among 3791 youths with nonfatal opioid overdose, 2234 (58.9%) were female, and 2491 (65.7%) were non-Hispanic white. The median age was 18 years (interquartile range, 16-20 years). The crude incident opioid overdose rate was 44.1 per 100 000 person-years. Of these 3791 youths, 1001 (26.4%) experienced a heroin overdose; the 2790 (73.6%) remaining youths experienced an overdose involving other opioids. The risk of recurrent overdose among youths with incident heroin involvement was significantly higher than that among youths with other opioid overdose (adjusted hazard ratio, 2.62; 95% CI, 2.14-3.22), and youths with incident heroin overdose experienced recurrent overdose at a crude rate of 20 700 per 100 000 person-years. Of 3606 youths with opioid-related overdose and continuous enrollment for at least 30 days after overdose, 2483 (68.9%) received no addiction treatment within 30 days after incident opioid overdose, whereas only 1056 youths (29.3%) received behavioral health services alone, and 67 youths (1.9%) received pharmacotherapy. Youths with heroin overdose were significantly less likely than youths with other opioid overdose to receive any treatment after their overdose (adjusted odds ratio, 0.64; 95% CI, 0.49-0.83).

Conclusions And Relevance: After opioid overdose, less than one-third of youths received timely addiction treatment, and only 1 in 54 youths received recommended evidence-based pharmacotherapy. Interventions are urgently needed to link youths to treatment after overdose, with priority placed on improving access to pharmacotherapy.
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http://dx.doi.org/10.1001/jamapediatrics.2019.5183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990723PMC
March 2020

Psychiatric Readmission of Children and Adolescents: A Systematic Review and Meta-Analysis.

Psychiatr Serv 2020 03 11;71(3):269-279. Epub 2019 Dec 11.

Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles (Edgcomb, Zima); Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati, Cincinnati (Sorter); Department of Psychiatry, University of Massachusetts Medical School, Worcester (Lorberg).

Objective: To investigate predictors of psychiatric hospital readmission of children and adolescents, a systematic review and meta-analysis was conducted.

Methods: Following PRISMA statement guidelines, a systematic literature search of articles published between 1997 and 2018 was conducted in PubMed/MEDLINE, Google Scholar, and PsycINFO for original peer-reviewed articles investigating predictors of psychiatric hospital readmission among youths (<18 years old). Effect sizes were extracted and combined by using random-effects meta-analysis. Covariates were investigated with meta-regression and subgroup analyses.

Results: Thirty-three studies met inclusion criteria, containing information on 83,361 children and adolescents, of which raw counts of readmitted vs. non-readmitted youths were available for 76,219. Of these youths, 13.2% (N=10,076) were readmitted. The mean±SD study follow-up was 15.9±15.0 months, and time to readmission was 13.1±12.8 months. Readmission was associated with, but not limited to, suicidal ideation at index hospitalization (pooled odds ratio [OR]=2.35, 95% confidence interval [CI]=1.64-3.37), psychotic disorders (OR=1.87, 95% CI=1.53-2.28), prior hospitalization (OR=2.51, 95% CI=1.76-3.57), and discharge to residential treatment (OR=1.84, 95% CI=1.07-3.16). There was evidence of moderate study bias. Prior investigations were methodologically and substantively heterogeneous, particularly for measurement of family-level factors.

Conclusions: Interventions to reduce child psychiatric readmissions should place priority on youths with indicators of high clinical severity, particularly with a history of suicidality, psychiatric comorbidity, prior hospitalization, and discharge to residential treatment. Standardization of methods to determine prevalence rates of readmissions and their predictors is needed to mitigate potential biases and inform a national strategy to reduce repeated child psychiatric hospital readmissions.
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http://dx.doi.org/10.1176/appi.ps.201900234DOI Listing
March 2020

Depression, Anxiety, and Emergency Department Use for Asthma.

Pediatrics 2019 10;144(4)

Departments of Pediatrics.

Background And Objectives: Asthma is responsible for ∼1.7 million emergency department (ED) visits annually in the United States. Studies in adults have shown that anxiety and depression are associated with increased asthma-related ED use. Our objective was to assess this association in pediatric patients with asthma.

Methods: We identified patients aged 6 to 21 years with asthma in the Massachusetts All-Payer Claims Database for 2014 to 2015 using codes. We examined the association between the presence of anxiety, depression, or comorbid anxiety and depression and the rate of asthma-related ED visits per 100 child-years using bivariate and multivariable analyses with negative binomial regression.

Results: Of 65 342 patients with asthma, 24.7% had a diagnosis of anxiety, depression, or both (11.2% anxiety only, 5.8% depression only, and 7.7% both). The overall rate of asthma-related ED use was 17.1 ED visits per 100 child-years (95% confidence interval [CI]: 16.7-17.5). Controlling for age, sex, insurance type, and other chronic illness, patients with anxiety had a rate of 18.9 (95% CI: 17.0-20.8) ED visits per 100 child-years, patients with depression had a rate of 21.7 (95% CI: 18.3-25.0), and patients with both depression and anxiety had a rate of 27.6 (95% CI: 24.8-30.3). These rates were higher than those of patients who had no diagnosis of anxiety or depression (15.5 visits per 100 child-years; 95% CI: 14.5-16.4; < .001).

Conclusions: Children with asthma and anxiety or depression alone, or comorbid anxiety and depression, have higher rates of asthma-related ED use compared with those without either diagnosis.
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http://dx.doi.org/10.1542/peds.2019-0856DOI Listing
October 2019

Treatment for Nicotine Use Disorder Among Medicaid-Enrolled Adolescents and Young Adults.

JAMA Pediatr 2019 Sep 23. Epub 2019 Sep 23.

Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamapediatrics.2019.3200DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6763988PMC
September 2019

Trends in Pediatric Emergency Department Visits for Mental Health Conditions and Disposition by Presence of a Psychiatric Unit.

Acad Pediatr 2019 Nov - Dec;19(8):948-955. Epub 2019 Jun 5.

Division of Emergency Medicine (JA Hoffmann, MI Neuman), Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Mass.

Objective: To examine trends in mental health (MH) visits to pediatric emergency departments (EDs) and identify whether ED disposition varies by presence of a hospital inpatient psychiatric unit (IPU).

Study Design: Cross-sectional study of 8,479,311 ED visits to 35 children's hospitals from 2012 to 2016 for patients aged 3 to 21 years with a primary MH or non-MH diagnosis. Multivariable generalized estimating equations and bivariate Rao-Scott chi-square tests were used to examine trends in ED visits and ED disposition by IPU status, adjusted for clustering by hospital.

Results: From 2012 to 2016, hospitals experienced a greater increase in ED visits with a primary MH versus non-MH diagnosis (50.7% vs 12.7% cumulative increase, P < .001). MH visits were associated with patients who were older, female, white non-Hispanic, and privately insured compared with patients of non-MH visits (all P < .001). Forty-four percent of MH visits in 2016 had a primary diagnosis of depressive disorders or suicide or self-injury, and the increase in visits was highest for these diagnosis groups (depression: 109.8%; suicide or self-injury: 110.2%). Among MH visits, presence of a hospital IPU was associated with increased hospitalizations (34.6% vs 22.5%, P < .001) and less transfers (9.2% vs 16.2%, P < .001).

Conclusion: The increase in ED MH visits from 2012 to 2016 was 4 times greater than non-MH visits at US children's hospitals and was primarily driven by patients diagnosed with depressive disorders and suicide or self-injury. Our findings have implications for strategic planning in tertiary children's hospitals dealing with a rising demand for acute MH care.
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http://dx.doi.org/10.1016/j.acap.2019.05.132DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7122010PMC
August 2020

Utilization of Child Psychiatry Consultation Embedded in Primary Care for an Urban, Latino Population.

J Health Care Poor Underserved 2019 ;30(2):637-652

Objective: In a novel model of embedded primary care child psychiatry serving an urban Latino population, we examined determinants of successful referral and relationship between clinical need and service intensity.

Methods: We conducted a chart review of referred patients from July 2013-March 2015. We used multiple logistic regressions controlling for confounders to identify determinants of successful referral. We examined the relationship between service intensity and clinical need using Poisson regression, adjusting for exposure time, age, sex, ethnicity, and language.

Results: Seventy-four percent of patients completed an evaluation. Younger children (p=.0397) and those with a history of therapy (p=.0077) were more likely to make initial contact. The markers of clinical need included PSC-35 Global Scores (p=.0027) and number of psychiatric diagnoses (p=.0178) predicted number of visits.

Conclusions: Our findings support early referral to improve engagement, and provide initial evidence that embedded child psychiatry consultation is feasible and may increase access to care.
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http://dx.doi.org/10.1353/hpu.2019.0047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6750951PMC
March 2020

Community Interventions to Promote Mental Health and Social Equity.

Curr Psychiatry Rep 2019 03 29;21(5):35. Epub 2019 Mar 29.

Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.

Purpose Of Review: We review recent community interventions to promote mental health and social equity. We define community interventions as those that involve multi-sector partnerships, emphasize community members as integral to the intervention, and/or deliver services in community settings. We examine literature in seven topic areas: collaborative care, early psychosis, school-based interventions, homelessness, criminal justice, global mental health, and mental health promotion/prevention. We adapt the social-ecological model for health promotion and provide a framework for understanding the actions of community interventions.

Recent Findings: There are recent examples of effective interventions in each topic area. The majority of interventions focus on individual, family/interpersonal, and program/institutional social-ecological levels, with few intervening on whole communities or involving multiple non-healthcare sectors. Findings from many studies reinforce the interplay among mental health, interpersonal relationships, and social determinants of health. There is evidence for the effectiveness of community interventions for improving mental health and some social outcomes across social-ecological levels. Studies indicate the importance of ongoing resources and training to maintain long-term outcomes, explicit attention to ethics and processes to foster equitable partnerships, and policy reform to support sustainable healthcare-community collaborations.
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http://dx.doi.org/10.1007/s11920-019-1017-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6440941PMC
March 2019

Validation of the Traumatic Events Screening Inventory for ACEs.

Pediatrics 2019 04 5;143(4). Epub 2019 Mar 5.

Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, California.

Objectives: Our purpose in this study was to adapt and validate the Traumatic Events Screening Inventory (TESI) as a primary-care childhood adversity screening tool for children living in vulnerable neighborhoods using a community-partnered approach.

Methods: In this cross-sectional, descriptive study, we used a sample of 261 children (3-16 years old) who were seeking services at a Federally Qualified Health Center with colocated behavioral health services in Chicago and had a positive Pediatric Symptom Checklist screen result or received a referral for behavioral health evaluation. The TESI was adapted as a screening tool to be sensitive to adverse childhood experiences (ACEs) unique to the clinic communities. ACEs were mapped by zip code with objective neighborhood crime data, and latent class analysis was performed to identify ACE subgroups.

Results: The mapping validation suggested face validity for geographic overlap between participant ACEs and objective violent-crime occurrence. With latent class analysis, we identified 3 ACE subgroups: (1) high ACE (18.0% of the sample; polyvictimization and/or maltreatment), (2) moderate ACE (52.1%; violent environments), and (3) low ACE (29.9%; few adverse experiences). Membership in the high-ACE subgroup was associated with higher odds of a clinically significant Pediatric Symptom Checklist score (odds ratio = 3.83) and clinical-level attention problems (odds ratio = 3.58) even after accounting for child resilience and parent depression.

Conclusions: ACEs play a significant role in predicting a need for behavioral health services among children seeking primary-care services. The community-adapted TESI is a valid ACE screening tool.
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http://dx.doi.org/10.1542/peds.2018-2546DOI Listing
April 2019

Selection of a Child Clinical Outcome Measure for Statewide Use in Publicly Funded Outpatient Mental Health Programs.

Psychiatr Serv 2019 05 28;70(5):381-388. Epub 2019 Feb 28.

University of California, Los Angeles (UCLA), Semel Institute for Neuroscience and Human Behavior (Zima, Marti) and UCLA Center for Health Policy Research, Fielding School of Public Health (Lee, Pourat), UCLA.

Objective: This study describes the process of choosing a clinical outcome measure for a statewide performance outcome system for children receiving publicly funded mental health services in California.

Methods: The recommendation is based on a five-phase approach, including an environmental scan of measures used by state mental health agencies; a statewide provider survey; a scientific literature review; a modified Delphi panel; and final rating of candidate measures by using nine minimum criteria informed by stakeholder priorities, scientific evidence, and state statute.

Results: Only 10 states reported use of at least one standardized measure for outcome measurement. In California, the most frequently reported measures were the Child and Adolescent Needs and Strengths (CANS) (N=33), the Child Behavior Checklist (N=14), and the Eyberg Child Behavior Inventory (N=12). Based on modified Delphi panel ratings, only the Achenbach System of Empirically Based Assessment, the Strengths and Difficulties Questionnaire, and the Pediatric Symptom Checklist (PSC) were rated on average in the high-equivocal to high range on effective care, scientific acceptability, usability, feasibility, and overall utility. The PSC met all nine minimum criteria for recommendation for statewide use. In its final decision, the California Department of Health Care Services mandated use of the PSC and CANS.

Conclusions: There is a lack of capacity to compare child clinical outcomes across states and California counties. Frequently used outcome measures were often not supported by scientific evidence or Delphi panel ratings. Policy action is needed to promote the selection of a common clinical outcome measure and measurement methodology for children receiving publicly funded mental health care.
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http://dx.doi.org/10.1176/appi.ps.201800424DOI Listing
May 2019

A Telehealth-Enhanced Referral Process in Pediatric Primary Care: A Cluster Randomized Trial.

Pediatrics 2019 03 15;143(3). Epub 2019 Feb 15.

Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, California.

: media-1vid110.1542/5984243450001PEDS-VA_2018-2738 OBJECTIVES: To improve the mental health (MH) referral process for children referred from primary care to community mental health clinics (CMHCs) by using a community-partnered approach.

Methods: Our partners were a multisite federally qualified health center and 2 CMHCs in Los Angeles County. We randomly assigned 6 federally qualified health center clinics to the intervention or as a control and implemented a newly developed telehealth-enhanced referral process (video orientation to the CMHC and a live videoconference CMHC screening visit) for all MH referrals from the intervention clinics. Our primary outcome was CMHC access defined by completion of the initial access point for referral (CMHC screening visit). We used multivariate logistic and linear regression to examine intervention impact on our primary outcome. To accommodate the cluster design, we used mixed-effect regression models.

Results: A total of 342 children ages 5 to 12 were enrolled; 86.5% were Latino, 61.7% were boys, and the mean age at enrollment was 8.6 years. Children using the telehealth-enabled referral process had 3 times the odds of completing the initial CMHC screening visit compared with children who were referred by using usual care procedures (80.49% vs 64.04%; adjusted odds ratio 3.02 [95% confidence interval 1.47 to 6.22]). Among children who completed the CMHC screening visit, intervention participants took 6.6 days longer to achieve it but also reported greater satisfaction with the referral system compared with controls. Once this initial access point in referral was completed, >80% of eligible intervention and control participants (174 of 213) went on to an MH visit.

Conclusions: A novel telehealth-enhanced referral process developed by using a community-partnered approach improved initial access to CMHCs for children referred from primary care.
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http://dx.doi.org/10.1542/peds.2018-2738DOI Listing
March 2019

National Child Mental Health Quality Measures: Adherence Rates and Extent of Evidence for Clinical Validity.

Curr Psychiatry Rep 2019 01 31;21(1). Epub 2019 Jan 31.

American Psychiatric Association, Washington, DC, USA.

Purpose Of Review: To provide an overview of the selection process and annual updates of the child mental health measures within the Child Core Set, describe national and statewide adherence rates, and summarize findings from a systematic literature review examining measure adherence rates and whether adherence is associated with improved clinical outcomes.

Recent Findings: Five national quality measures target child mental health care processes. On average, national adherence varied widely by state, and performance did not substantially improve during the past 5 years. Mean national adherence rates for the two measures related to timeliness of care were below 50%. For each measure, scientific evidence to support the association between adherence and improved clinical outcomes was scarce. Investment in academic-agency partnered research to standardize methods for publicly reporting adherence to national child mental health quality measures and validation of these measures should be a national priority for child healthcare research.
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http://dx.doi.org/10.1007/s11920-019-0986-3DOI Listing
January 2019

National Child Mental Health Quality Measures: Adherence Rates and Extent of Evidence for Clinical Validity.

Curr Psychiatry Rep 2019 01 31;21(1). Epub 2019 Jan 31.

American Psychiatric Association, Washington, DC, USA.

Purpose Of Review: To provide an overview of the selection process and annual updates of the child mental health measures within the Child Core Set, describe national and statewide adherence rates, and summarize findings from a systematic literature review examining measure adherence rates and whether adherence is associated with improved clinical outcomes.

Recent Findings: Five national quality measures target child mental health care processes. On average, national adherence varied widely by state, and performance did not substantially improve during the past 5 years. Mean national adherence rates for the two measures related to timeliness of care were below 50%. For each measure, scientific evidence to support the association between adherence and improved clinical outcomes was scarce. Investment in academic-agency partnered research to standardize methods for publicly reporting adherence to national child mental health quality measures and validation of these measures should be a national priority for child healthcare research.
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http://dx.doi.org/10.1007/s11920-019-0986-3DOI Listing
January 2019

Medicaid Expenditures Among Children With Noncomplex Chronic Diseases.

Pediatrics 2018 11 2;142(5). Epub 2018 Oct 2.

Department of Psychiatry and Behavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.

Background And Objectives: Expenditures for children with noncomplex chronic diseases (NC-CDs) are related to disease chronicity and resource use. The degree to which specific conditions contribute to high health care expenditures among children with NC-CDs is unknown. We sought to describe patient characteristics, expenditures, and use patterns of children with NC-CDs with the lowest (≤80th percentile), moderate (81-95th percentile), high (96-99th percentile), and the highest (≥99th percentile) expenditures.

Methods: In this retrospective cross-sectional study, we used the 2014 Truven Medicaid MarketScan Database for claims from 11 states. We included continuously enrolled children (age <18 years) with NC-CDs ( = 1 563 233). We describe per member per year (PMPY) spending and use by each expenditure group for inpatient services, outpatient services, and the pharmacy for physical and mental health conditions. K-means clustering was used to identify expenditure types for the highest expenditure group.

Results: Medicaid PMPY spending ranged from $1466 (lowest expenditures) to $57 300 (highest expenditures; < .001); children in the highest expenditure group were diagnosed with a mental health condition twice as often (72.7% vs 34.1%). Cluster analysis was used to identify 3 distinct groups: 83% with high outpatient mental health expenditures ( = 13 033; median PMPY $18 814), 15% with high inpatient expenditures ( = 2386; median PMPY $92 950), and 1% with high pharmacy expenditures ( = 213; median $325 412). Mental health conditions accounted for half of the inpatient diagnoses in the cluster analysis.

Conclusions: One percent of children with the highest expenditures accounted for 20% of Medicaid expenditures in children with NC-CDs; mental health conditions account for a large proportion of aggregate Medicaid spending in children with NC-CDs.
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http://dx.doi.org/10.1542/peds.2018-0286DOI Listing
November 2018

Receipt of Timely Addiction Treatment and Association of Early Medication Treatment With Retention in Care Among Youths With Opioid Use Disorder.

JAMA Pediatr 2018 11;172(11):1029-1037

Semel Institute for Neuroscience and Human Behavior, UCLA (University of California, Los Angeles), Los Angeles.

Importance: Retention in addiction treatment is associated with reduced mortality for individuals with opioid use disorder (OUD). Although clinical trials support use of OUD medications among youths (adolescents and young adults), data on timely receipt of buprenorphine hydrochloride, naltrexone hydrochloride, and methadone hydrochloride and its association with retention in care in real-world treatment settings are lacking.

Objectives: To identify the proportion of youths who received treatment for addiction after diagnosis and to determine whether timely receipt of OUD medications is associated with retention in care.

Design, Setting, And Participants: This retrospective cohort study used enrollment data and complete health insurance claims of 2.4 million youths aged 13 to 22 years from 11 states enrolled in Medicaid from January 1, 2014, to December 31, 2015. Data analysis was performed from August 1, 2017, to March 15, 2018.

Exposures: Receipt of OUD medication (buprenorphine, naltrexone, or methadone) within 3 months of diagnosis of OUD compared with receipt of behavioral health services alone.

Main Outcomes And Measures: Retention in care, with attrition defined as 60 days or more without any treatment-related claims.

Results: Among 4837 youths diagnosed with OUD, 2752 (56.9%) were female and 3677 (76.0%) were non-Hispanic white. Median age was 20 years (interquartile range [IQR], 19-21 years). Overall, 3654 youths (75.5%) received any treatment within 3 months of diagnosis of OUD. Most youths received only behavioral health services (2515 [52.0%]), with fewer receiving OUD medications (1139 [23.5%]). Only 34 of 728 adolescents younger than 18 years (4.7%; 95% CI, 3.1%-6.2%) and 1105 of 4109 young adults age 18 years or older (26.9%; 95% CI, 25.5%-28.2%) received timely OUD medications. Median retention in care among youths who received timely buprenorphine was 123 days (IQR, 33-434 days); naltrexone, 150 days (IQR, 50-670 days); and methadone, 324 days (IQR, 115-670 days) compared with 67 days (IQR, 14-206 days) among youths who received only behavioral health services. Timely receipt of buprenorphine (adjusted hazard ratio, 0.58; 95% CI, 0.52-0.64), naltrexone (adjusted hazard ratio, 0.54; 95% CI, 0.43-0.69), and methadone (adjusted hazard ratio, 0.32; 95% CI, 0.22-0.47) were each independently associated with lower attrition from treatment compared with receipt of behavioral health services alone.

Conclusions And Relevance: Timely receipt of buprenorphine, naltrexone, or methadone was associated with greater retention in care among youths with OUD compared with behavioral treatment only. Strategies to address the underuse of evidence-based medications for youths with OUD are urgently needed.
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http://dx.doi.org/10.1001/jamapediatrics.2018.2143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6218311PMC
November 2018

Development of a Telehealth-Coordinated Intervention to Improve Access to Community-Based Mental Health.

Ethn Dis 2018 6;28(Suppl 2):457-466. Epub 2018 Sep 6.

University of Washington School of Medicine, Seattle Children's Research Institute, Seattle, WA.

Objective: To develop an intervention to improve the mental health referral and care process for children referred by primary care providers (PCPs) to community mental health clinics (MHCs) using a community partnered approach.

Design: A Project Working Group (PWG) with representatives from each partner organization met monthly for 6 months.

Setting: Multi-site federally qualified health center (FQHC) and two community MHCs in Los Angeles county.

Participants: 26 stakeholders (14 FQHC clinic providers/staff, 8 MHC providers/staff, 4 parents) comprised the PWG.

Data Sources: Qualitative interviews, PWG meeting notes, intervention processes and workflow reports.

Intervention: The PWG reviewed qualitative data from stakeholders (interviews of 7 parents and 13 providers/staff). The PWG met monthly to identify key transition points where access to and coordination of care were likely compromised and to develop solutions.

Results: Three critical transition points and system solutions were identified: 1) Parents refuse initial referral to the MHC due to stigma regarding mental health services. During initial referral, parents watch a video introducing them to the MHC. 2) Parents don't complete the MHC's screening after referral. A live videoconference session connecting parents at the FQHC with MHC staff ensures completion of the screening and eligibility process. 3) PCPs reject transfer of patients back to primary care for ongoing psychotropic medication management. Regularly scheduled live videoconferences connect PCPs and MHC providers.

Conclusions: A community partnered approach to care design utilizing telehealth for care coordination between clinics can potentially be used to address key challenges in MHC access for children.
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http://dx.doi.org/10.18865/ed.28.S2.457DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6128350PMC
October 2019

Development and Evaluation of Two Integrated Care Models for Children Using a Partnered Formative Evaluation Approach.

Ethn Dis 2018 6;28(Suppl 2):445-456. Epub 2018 Sep 6.

Department of Psychiatry, University of California at San Francisco, CA.

Objective: To describe the development and evaluation of two integrated care models using a partnered formative evaluation approach across a private foundation, clinic leaders, providers and staff, and a university-based research center.

Design: Retrospective cohort study using multiple data sources.

Setting: Two federal qualified health care centers serving low-income children and families in Chicago.

Participants: Private foundation, clinic and academic partners.

Interventions: Development of two integrated care models and partnered evaluation design.

Main Outcome Measures: Accomplishments and early lessons learned.

Results: Together, the foundation-clinic-academic partners worked to include best practices in two integrated care models for children while developing the evaluation design. A shared data collection approach, which empowered the clinic partners to collect data using a web-based tool for a prospective longitudinal cohort study, was also created.

Conclusion: Across three formative evaluation stages, the foundation, clinic, and academic partners continued to reach beyond their respective traditional roles of project oversight, clinical service, and research as adjustments were collectively made to accommodate barriers and unanticipated events. Together, an innovative shared data collection approach was developed that extends partnered research to include data collection being led by the clinic partners and supported by the technical resources of a university-based research center.
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http://dx.doi.org/10.18865/ed.28.S2.445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6128333PMC
October 2019

Evaluation of the Mental Health Services Act in Los Angeles County: Implementation and Outcomes for Key Programs.

Rand Health Q 2018 Aug 2;8(1). Epub 2018 Aug 2.

Los Angeles County used Mental Health Services Act (MHSA) funds to greatly expand access to Full-Service Partnership (FSP) services and offer new prevention and early intervention (PEI) services. This study examines the reach of key MHSA-funded activities and what the impact of those activities has been, with a focus on PEI programs for children and transition-age youth (TAY) and FSP programs for children, TAY, and adults. The evaluation found evidence that the Los Angeles County Department of Mental Health (LAC DMH) is reaching the highly vulnerable population it seeks to reach with its FSP and youth PEI programs. Furthermore, those reached by the programs experience improvements in their mental health and life circumstances. Refining data collection will enable more-thorough evaluation of processes of care and would inform the program's quality-improvement efforts.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6075804PMC
August 2018

Mental Health Conditions and Unplanned Hospital Readmissions in Children.

J Hosp Med 2018 07;13(7):445-452

Department of Medicine, Division of General Pediatrics, Complex Care Service, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Objective: Mental health conditions (MHCs) are prevalent among hospitalized children and could influence the success of hospital discharge. We assessed the relationship between MHCs and 30-day readmissions.

Methods: This retrospective, cross-sectional study of the 2013 Nationwide Readmissions Database included 512,997 hospitalizations of patients ages 3 to 21 years for the 10 medical and 10 procedure conditions with the highest number of 30-day readmissions. MHCs were identified by using the International Classification of Diseases, 9th Revision-Clinical Modification codes. We derived logistic regression models to measure the associations between MHC and 30-day, all-cause, unplanned readmissions, adjusting for demographic, clinical, and hospital characteristics.

Results: An MHC was present in 17.5% of medical and 13.1% of procedure index hospitalizations. Readmission rates were 17.0% and 6.2% for medical and procedure hospitalizations, respectively. In the multivariable analysis, compared with hospitalizations with no MHC, hospitalizations with MHCs had higher odds of readmission for medical admissions (adjusted odds ratio [AOR], 1.23; 95% confidence interval [CI], 1.19-1.26] and procedure admissions (AOR, 1.24; 95% CI, 1.15-1.33). Three types of MHCs were associated with higher odds of readmission for both medical and procedure hospitalizations: depression (medical AOR, 1.57; 95% CI, 1.49-1.66; procedure AOR, 1.39; 95% CI, 1.17-1.65), substance abuse (medical AOR, 1.24; 95% CI, 1.18-1.30; procedure AOR, 1.26; 95% CI, 1.11-1.43), and multiple MHCs (medical AOR, 1.43; 95% CI, 1.37-1.50; procedure AOR, 1.26; 95% CI, 1.11-1.44).

Conclusions: MHCs are associated with a higher likelihood of hospital readmission in children admitted for medical conditions and procedures. Understanding the influence of MHCs on readmissions could guide strategic planning to reduce unplanned readmissions for children with cooccurring physical and mental health conditions.
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http://dx.doi.org/10.12788/jhm.2910DOI Listing
July 2018