Mental Health Revisits at US Pediatric Emergency Departments

Abstract

Importance: Pediatric emergency department (ED) visits for mental health crises are increasing. Patients who frequently use the ED are of particular concern, as pediatric mental health ED visits are commonly repeat visits. Better understanding of trends and factors associated with mental health ED revisits is needed for optimal resource allocation and targeting of prevention efforts.

Objective: To describe trends in pediatric mental health ED visits and revisits and to determine factors associated with revisits.

Design, setting, and participants: In this cohort study, data were obtained from 38 US children's hospital EDs in the Pediatric Health Information System between October 1, 2015, and February 29, 2020. The cohort included patients aged 3 to 17 years with a mental health ED visit.

Exposures: Characteristics of patients, encounters, hospitals, and communities.

Main outcomes and measures: The primary outcome was a mental health ED revisit within 6 months of the index visit. Trends were assessed using cosinor analysis and factors associated with time to revisit using mixed-effects Cox proportional hazards regression.

Results: There were 308 264 mental health ED visits from 217 865 unique patients, and 13.2% of patients had a mental health revisit within 6 months. Mental health visits increased by 8.0% annually (95% CI, 4.5%-11.4%), whereas all other ED visits increased by 1.5% annually (95% CI, 0.1%-2.9%). Factors associated with mental health ED revisits included psychiatric comorbidities, chemical restraint use, public insurance, higher area measures of child opportunity, and presence of an inpatient psychiatric unit at the presenting hospital. Patients with psychotic disorders (hazard ratio [HR], 1.42; 95% CI, 1.29-1.57), disruptive or impulse control disorders (HR, 1.36; 95% CI, 1.30-1.42), and neurodevelopmental disorders (HR, 1.22; 95% CI, 1.14-1.30) were more likely to revisit. Patients with substance use disorders (HR, 0.60; 95% CI, 0.55-0.66) were less likely to revisit.

Conclusions and relevance: Markers of disease severity and health care access were associated with mental health revisits. Directing hospital and community interventions toward identified high-risk patients is needed to help mitigate recurrent mental health ED use and improve mental health care delivery.

Figure 1.. Flowchart of Included Patients

Visits from patients older than 18 years were included in the data set initially to capture revisits that occurred after a patient’s 18th birthday for those patients who were younger than 18 at the index visit and had a mental health emergency department revisit after turning 18. Those visits in which they were aged 18 years or older were then excluded from further visit counts and trend analyses. PHIS indicates Pediatric Health Information System.

Figure 2.. Change in Pediatric Mental Health Emergency Department (ED) Visits