The Relationship of Parental Psychopathology and Pain Related Medical Problems to Child Medical Management and Avoidable Emergency Pediatric Services

THE RELATIONSHIP OF PARENTAL PSYCHOPATHOLOGY AND PAIN-RELATED CONDITIONS TO CHILD MEDICAL MANAGEMENT AND AVOIDABLE EMERGENCY PEDIATRIC SERVICES Prepared by: Joseph E. Logan, PhD Health Services Research Department of Health Policy and Management The Johns Hopkins University Bloomberg School of Hygiene and Public Health Funding Source: NIMH T32 MH 19545 Introduction Many children experience problems receiving timely non-emergency based outpatient care.  Lack of preventive services (e.g. well-child visits, annual checkups) Avoidable ED visits and hospitalizations, also known as Ambulatory Care Sensitive services (ACS-ED visits and ACS hospitalizations)  (Casanova & Starfield, 1995; Parker & Schoendorf, 2000; Kansas Health Statistics, KDHE Center for Health and Environmental Statistics, 2001; Oster & Bindman, 2003 ) Factors Associated with Inadequate Use of Pediatric Services       Family income and insurance status Poor or rural areas Race Lack of provider education and follow-up Child’s age Single Parenthood (Parker & Schoendorf, 2000; Oster & Bindman, 2003; Flores et al., 2003) Factors Associated with Inadequate Use of Pediatric Services      Parental awareness of signs and symptoms Parental ability to navigate the health system Parental compliance with providers recommendations Maternal depressive symptoms Parental pain-related medical conditions? (Flores et al., 2003; Gaskin & Mitchell, 2005; Minkovitz et al., 2005; Emptage et al., 2005) Study Objectives 1. To investigate whether parental emotional and pain-related distress is associated with a lack of well-child care. To determine the types of parental emotional and pain-related diagnoses most predictive of ACS-ED visits and ACS hospitalizations in children (1-18 years) To explore the time interval for when children were most at risk for unstable health with respect to their mother’s depressive episodes 2. 3. 4. To assess whether treatments for maternal depression can moderate the likelihood of inadequate management of children’s medical care needs. Conceptual Framework Environmental Factors •Socio-Economic Resources •Community Culture •Geographic Location •Stigma •Work and Home Life •Quality of Health Care •Family Size •School Access to Care •Siblings with Chronic Conditions •Teacher Awareness •Peer Influence Aim 1 Predisposing Health-Related Factors Enabling Factors NonEmergency Services Aim 2 •Mental Health & Medical Service Use Emergency Services & Hospitalizations Parent •Parental Mental & Pain-Related Conditions •Parental Attentiveness, Motivation & Ability •Financial Resources Child •Child Health •Age-Related Development •Preventive Services •Timely Service Use - •ACS-ED Visits •ACS Hospitalizations Study Design and Data Source   Observational study Data source: 1997-1998 Thomson/MEDSTAT’S MarketScan claims and administrative dataset Study Population  All parents were active users of the medical care system and all had private insurance with full access to medical and mental health care Parents and children had complete coverage for the full 2-year study Parents were adults over 18, listed as either a primary beneficiary or a spouse on the health plan, and had at least one child dependent    Children of parents with organic psychiatric conditions and children with any form of mental retardation were excluded. Child Population Characteristics     Low health service utilization (67%) A parent actively employed (93%) Both parents on the plan (82%) Parents between the ages of 31-50 (87%) Analysis for Aim 1 (cross-sectional design)  2-year child service use was compared among children whose parents were diagnosed with various mental health and pain-related conditions over the course of the study to children of parents without such diagnoses Logistic regression using Generalized Estimating Equations with robust variance estimates  Analytic Framework Independent Parental Mental Health and PainRelated Diagnoses Child Outcomes (-) Well-Child Visits (+) ACS-ED Visits (+) ACS Hospitalizations Parental attributes – parents’ age, employment, parent’s co-morbidity Child attributes - child co-morbidity and chronic health-related status, child age, child gender, Family Structure – family size (number of children in family), single parenthood (parents on plan) Health plan structure – type (MC v. FFS) Geographic location – 3 digit zipcodes Child Health Service Utilization in Relation to Maternal Health (odds ratios) Maternal Conditions Not having MH or PR Conditions Number of MH or PR Conditions 1 2 3 4 or more Number of MH Conditions: 1 2 3 4 or more Depression Bipolar Disorder Child Sample (Tot N=237,604) N 181,435 (%) 76.4 Well-Child Visits (2) 1 ACS-ED Visits 1 ACS Hospitaliz. * 1.01 0.86 b 0.78 c 0.89 0.95 0.85 c 0.87 0.72 * 1.30 a 1.47 a 1.55 a 1.79 a 1.28 a 1.32 a 1.48 a 1.57 c * 1.20 b 1.42 a 1.16 2.33 a 1.20 c 1.32 c 1.60 d 1.41 39,853 11,291 3,529 1,496 23,424 7,532 2,108 661 13,987 988 16.7 4.8 1.5 0.6 9.1 2.9 0.8 0.3 5.4 0.4 a = p<0.001 b = p<0.01 c = p<0.05 d = p<0.10 0.87c 0.72d 1.24a 1.50b 1.24d 1.63 Anxiety Personality Disorder Back Pain Arthritis 7,525 547 18,697 4,091 2.9 0.2 7.2 1.6 3.5 1.01 0.87 0.97 1.14 1.33a 1.56b 1.36a 1.96a 1.09 1.34a 1.32a 1.20a 1.32b 1.78a 1.13 1.13 1.60c 2.50a Migraine Headaches Depression with Anxiety Depression with Back Pain 8,985 2,100 2,068 1.00 0.85 0.97 0.8 0.8 Child Health Service Utilization in Relation to Paternal Health (odds ratios) Paternal Conditions Not Having MH or PR Conditions Number of MH or PR Conditions: 1 2 3 4 or more Number of MH Conditions: 1 2 3 4 or more Depression Schizophrenia Child Sample N 192,647 (%) 83.0 Well-Child Visits (2) 1 ACS-ED Visits 1 ACS Hospitaliz. * 1.00 1.04 1.00 1.31 0.91c 1.09 1.08 1.02 * 1.23 a 1.44 a 1.55 a 1.46 c 1.27 a 1.40 a 1.46 c 1.16 * 1.00 0.84 1.98b 0.60 1.02 1.10 1.27 1.22 31,080 6,201 1,610 614 15,120 4,179 1,014 348 6,808 119 13.4 2.7 0.7 0.2 5.9 1.6 0.4 0.1 2.6 0.05 a = p<0.001 b = p<0.01 c = p<0.05 d = p<0.10 0.99 1.15d 1.35d n/a 0.25d 0.96 1.04 1.16 0.92 0.96 1.88 1.29a 1.17b 1.37a 1.64a Adjustment Reaction Back Pain Migraine Headaches Depression with Adjustment Reaction 8,480 17,118 2,632 1,391 3.3 6.6 1.0 0.5 0.3 1.01 0.99 0.75 0.86 Adjustment Reaction with Back Pain 889 1.53c 1.73 Child Health Service Utilization in Relation to Co-Occurring Maternal and Paternal Health Conditions (odds ratios) Maternal Cond. Paternal Cond. Child Sample WellChild Visits (2) 67.0 0.1 1 ACSED Visits 1 ACS Hospitaliz. No MH or PR No MH or PR 141,701 * 1.26 * 1.88c * 3.00c 3 or more (any) 3 or more (any) 3 or more (MH) 3 or more (MH) Depression Depression 227 106 1,218 0.0 0.5 1.20 0.93 2.40c 1.40b 3.13 2.11b a = p<0.001; b = p<0.01; c = p<0.05 ; d = p<0.10 Analysis for Aim 2 (retrospective cohort design )  2-year study time-frame was divided into four 6-month study periods 4 cohorts were generated: 1.  2. 3. 4. Children whose mothers with continuous depression diagnoses Children whose mothers experienced a new episode in period 2 Children whose mothers experienced a new episode in period 3 Children whose mothers did not receive a depression diagnosis (reference group)  Poisson Regression and Cox-Proportional Hazards Models using GEE with robust variance estimates adjusting for the same variables in Aim 1 Incident Rate Ratios for the Likelihood that a Child Experienced an ACS-ED Visit or an ACS Hospitalization: Study Period Study Period Study Period Study Period 1 2 3 4 Maternal Frequency of January-June JulyJanuary-June JulyCharacteristics Children 1997 December 1998 December (n=237,615) 1997 1998 N No Depression Diagnosis Continuous Depression (w/o Hospitalization) Continuous Depression (with Hospitalization) Jul-Dec.97 NewEpisode Mothers (w/o Hospitalization) % ED * Hos * ED * Hos * ED * Hos * ED * Hos * 184,017 77.4 1,373 92 0.58 0.04 1.37 0.33 1.51d 1.06 1.43d 1.55 1.11 2.21 4.48b 3.00d 2.13 3.01 3.76b 7.09b 1.14 n/a 1,886 0.80 1.33 1.34 1.53c 1.68 1.36 1.07 1.18 1.39 a = p<0.001; b = p<0.01; c = p<0.05 ; d = p<0.10; n/a = sample too small to estimate variability Incident Rate Ratios for the Likelihood that a Child Experienced an ACS-ED Visit or an ACS Hospitalization: Study Period 1 January-June 1997 ED * Hos * Study Period 2 JulyDecember 1997 ED * Hos * Study Period 3 January-June 1998 ED * 1.43d 3.76b Hos * Study Period 4 JulyDecember 1998 ED * Hos * Maternal Characteristics Frequency of Children (n=237,645) N % No Depression Diagnosis Continuous Depression (w/o Hospitalization) Continuous Depression (with Hospitalization) Jan.-Jun. 98 New-Episodes (w/o Hospitalization) 184,017 77.4 1,373 0.58 1.37 0.33 1.51d 1.06 1.55 1.11 2.21 92 0.04 4.48b 3.00d 2.13 3.01 7.09b 1.14 n/a 2,894 1.22 1.33 0.58 1.22 0.51 1.80a 1.45 1.65b 2.54b a = p<0.001; b = p<0.01; c = p<0.05 ; d = p<0.10; n/a = sample too small to estimate variability The Hazard Ratio and 95% Confidence Intervals for a Child Experiencing an ACS-ED Visit During their Mother’s Treatment Period by the Mother’s Adherence to Treatment: Maternal Treatment Frequency Model 1: Model 2: Model 3: All Child Adherence Status of children No Other All Child Variables with Maternal (Total Variables Variables Propensity Score N=4,780) Adhere Propensity N (%) Coef. Coef. Non-adherent to Any Treatments 1,887 39.5 * * * * Adherent to Any Therapy Adherent to Drug Therapy Only Adherent to Psychotherapy Only Adherent to Drug Therapy and Psychotherapy 2,893 60.5 2,019 42.2 490 10.3 1.22 (.80,1.86) 1.04 (.65,1.65) 1.71 (.90, 3.23)d 1.54 (.74,3.19) 1.27 (.81,2.00) 1.06 (.64,1.72) (1.13,4.29)c 1.41 (.65,3.07) 1.28 (.81,2.02) 0.99 (.61,1.58) (1.01,4.10)c 1.62 (.73,3.58) 0.21 (.03,1.29)d 1.43 (.35,5.90) 0.39 (.06,2.58) 0.04 (.001,1.09)c 2.20 2.04 384 8.0 a = p<0.001; b = p<0.01; c = p<0.05 ; d = p<0.10 Implications  Pediatricians should consider parental mental health as they seek to manage child health, especially if the parent has a cooccurring pain-related condition Mental Health Providers should increase monitoring of dependents whose caregivers initiate mental health treatments  Descriptive Characteristics Children Age (%) a,b 0-5 6-10 11-13 14-18 Resource Utilization Band (RUB) (%)a,b,c 0-1 2-3 4-5 Chronic Conditions (%) Time Limited Major Conditions a,b Asthma a,b Likely to Recur Conditionsa,b,c Chronic Medical (Unstable)a,b,c Chronic Ear-Nose-and-Throat Mothers Service at Initial Diagnosis (%) Physician Psychiatric Therapy Provider at Initial Diagnosis (%) Physician Non-Phys. Profess., Psychologist or Psychiatrist Acute Care Hosp or M. H. Fac. Undetermined Depression Severity (%) Moderate Severe Unspecified Resource Utilization Band (%) 0-1 2-3 4-5 Having a Mother Not Adhering to Therapy N=1,887 17.3 28.9 19.1 34.8 67.8 29.4 2.8 1.0 2.7 15.4 1.3 1.3 N=1,053 48.5 38.9 12.5 53.9 35.0 6.5 4.6 15.0 9.2 75.8 57.7 27.1 15.2 Having a Mother Adherent to Drug Therapy N=2,019 15.0 28.4 20.0 36.6 69.5 27.7 2.8 0.8 2.8 16.2 1.5 1.6 N=1,163 49.9 40.8 9.3 56.3 31.1 5.5 7.1 15.3 8.2 76.5 62.7 23.0 14.3 Having a Mother Using Psychotherapy N=490 20.2 29.2 18.0 32.7 58.0 39.6 2.5 0.8 2.9 20.2 2.9 1.2 N=271 5.2 72.0 22.9 16.2 74.2 8.5 1.1 31.0 16.6 52.4 44.3 33.6 22.1 Having a Mother Adherent to Combotherapy N=384 18.5 29.7 17.7 34.1 57.6 36.7 5.7 1.3 5.2 19.3 3.4 1.6 N=223 13.0 64.6 22.4 31.8 58.8 6.7 2.7 31.8 19.3 48.9 47.1 31.8 21.1 Child Characteristics Age (mean,sd) Gender (%) Male Female Region of Residence (%) Northeast North Central South West Unknown Family’s Plan Type (%) Basic/Comprehensive (Fee For service) Managed care Main Beneficiary’s Employment Status (%) Active Full Time Active Part Time, Early Retiree, or Other Study Pop Excluded Pop (N=258,331) (N=432,392) 9.7 (4.8) 51.3 48.7 26.7 34.1 30.0 8.7 0.5 33.7 66.3 93.1 6.9 8.4 (5.3) 51.4 48.6 25.3 24.4 27.6 19.2 3.6 28.7 71.3 85.6 14.4