This week, I am reading a study from researchers at the University of California Davis’ Departments of Pediatrics and Psychiatry, which uses a national data sample from the Healthcare Cost and Utilization Project 2014 Nationwide Emergency Department Sample (NEDS) to investigate the association between types of child health coverage and hospital decisions to admit or transfer patients (under 18) in cases where the child or adolescent was presenting with a mental health concern.

Pediatric Emergency Care’s Association Between Insurance and the Transfer of Children with Mental Health Emergencies

In 1986, the Emergency Medical Treatment and Labor Act (EMTALA) was enacted to prevent hospitals from transferring patients for reasons other than for “clinical necessity” such as lack of available specialists, support staff or resources. Researchers, however, are still finding evidence of ‘clinically inappropriate transfers’, which not only result in delay of care to a patient in need, but can also have devastating economic and logistical effects for a family including but not limited to facing more overcrowded emergency rooms, delays in accessing healthcare services and higher out-of-pocket costs.

The NEDS dataset is comprised of data from 945 hospitals across 33 states in the United States. The researchers excluded children presenting with suicidal ideation and/or self-harm behaviors (i.e. cutting) and diagnosis types that appeared less than 1% in the sample such as developmental disorders and delirium dementia and amnestic or cognitive disorders.

The study investigated the relationship between hospital admission or discharge with child insurance type (i.e. Medicaid, private employer-sponsored insurance, uninsured, etc.), excluding Medicare. Results were analyzed across diagnostic categories (i.e. depression, anxiety, schizophrenia), age group, geographic region, metropolitan/non-metropolitan location, teaching hospital status, and number of annual ER visits. Age groups were: 0 to 8, 9 to 12, and 13 to 17. The authors acknowledge some data limitations since the data set does not have variables to indicate availability of pediatric behavioral health specialist at transferring emergency department, severity/complexity of patient’s disorder, or specific resources available at the transferring emergency department.  The study also could not analyze whether transfers were clinically inappropriate or not.

What it finds:

• Of the resulting 19,081 national mental health pediatric emergency room visits investigated, 25.6% (4,890) resulted in a transfer whereas 74.4% (14,191) resulted in an admission. There were no observable differences when looking at patient age, sex, median household income, hospital region (i.e. Northwest, West, Midwest, South), or teaching status.
• Children who were uninsured had over 3 times higher likelihood of transfer (3.46 odds of transfer) relative to admission (50%) as compared to those children with private insurance (23.4%).
• Children with Medicaid and private coverage had comparable rates of transfer.
• Hospitals in non-metropolitan/rural settings had over 5 times the transfer rate as metropolitan hospitals.
• Hospitals with a larger volume of emergency department (ED) visits had lower likelihood of transfer compared to those with a lower volume of patients.
• The adjusted odds of transfer results indicate that uninsured children were significantly more likely (as compared to private insurance) to be transferred across 4 of the 9 diagnostic categories: depressive disorder, bipolar disorder, attention deficit and conduct disorder and schizophrenia.
• Researchers also find that children with personality disorders experienced the highest likelihood of transfer (8.8%).

Why it matters:

• Children and adolescents are experiencing high rates of mental health needs: The CDC indicates that 1 in 5 kids (ages 3-17), or about 15 million children, have a diagnosable mental, emotional or behavioral disorder in a given year and that only about 20% of these children receive the care they need. Furthermore, the crisis of child and adolescent mental health continues with recent increases in rates of youth experiencing psychological distress, major depression and suicidal thoughts; and study authors here note an intense need for more pediatric mental health outpatient options, a better triage system for mental health emergencies, more financial support for families without health insurance, and more research on creative interventions such as tele-psychiatry or child mobile crisis.
• More children are now uninsured and this means that they could be more likely to be inappropriately transferred if they present with mental health needs at an emergency room, which could result in delays in care, poorer health outcomes and higher out-of-pocket costs.