Follow-Up Found Lacking In Public MH Services

California's public mental health clinics evaluate children well but do only a “moderate to poor” job of sticking to quality indicators for patient care, said a study commissioned by the state's Department of Mental Health.

“Findings from this study raise serious questions about the adequacy of medical monitoring for children receiving psychoactive medication at Medicaid-funded public clinics,” said lead author Bonnie Zima, M.D., M.P.H., of the University of California, Los Angeles. “Almost three-fourths of the children receiving medication treatment did not have adequate monitoring of vital signs or laboratory studies.”

Initial clinical assessment of children met accepted standards 87.2 percent of the time, but documentation of parental involvement, linkage with schools or primary providers, patient safety, or psychosocial treatment generally fell below the 50 percent level, according to Zima and her colleagues, whose report appears in the February Journal of the American Academy of Child and Adolescent Psychiatry.

“This is a helpful reminder that there is a real need and a gap between developing evidence-based guidelines and actual practice,” said John Oldham, M.D., professor and chair of psychiatry and behavioral sciences at the Medical University of South Carolina in Charleston and chair of APA's Committee on Quality Care.

However, the study results should not be seen as criticism of doctors caring for very sick children, cautioned Zima. Rather, those doctors need more resources to do their jobs better.

“Doctors should have more time to monitor patients, contact schools, and document what they do,” she said. “They need better reimbursement, more support in the clinic, and more information technology.”

About 6 percent to 7.5 percent of children aged 3 to 17 use mental health services in the course of a year, estimated Zima, and Medicaid plays the largest public role in financing those services. Understanding whether children in these outpatient programs receive care that meets current treatment guidelines and practice parameters is important medically and economically.

“This is the first time a state department of mental health asked health-quality researchers to assess the quality of outpatient care for children in Medicaid-funded clinics,” she said. “And it's the first time anyone has assessed children with psychiatric disorders in the same way it's been done for surgery or other medical specialties.”

Zima and colleagues sampled chart records of children on Medicaid and compared them against evidence-based care recommendations and clinical consensus for three conditions: ADHD, conduct disorder, and major depression. They chose common conditions for which effective treatments were known.

The researchers selected 62 of 188 eligible clinics based on their treatment of children and adolescents, the number and percentage of Medicaid outpatient service contacts, and the number of new episodes of care for at least one of the three conditions. They then identified 4,958 records of patients who were between 6 and 17 years old and had at least three clinic visits in a 90-day period, but no visits in the 30 days before the initial visit date. The latter was a marker indicating a probable new episode of care. Out of 1,487 randomly selected records, 813 met all criteria for abstraction.

Standards were based on guidelines produced by national professional organizations such as the American Academy of Child and Adolescent Psychiatry, American Academy of Family Physicians, American Academy of Pediatrics, and other sources. A trained team of 12 registered nurses and one mental health professional abstracted the records.

While acknowledging that everything done for a patient might not be recorded in a chart, Zima said that documentation was a key to both assessment and care.

The children averaged 10.6 years old. About 34 percent were white, 24 percent were black, and 30 percent were Latino. About 26 percent met criteria for two conditions, of which two-thirds were identified as having ADHD and conduct disorder.

Although documentation of initial assessments was high, said the authors, other indications of basic treatment principles were not. The parents of barely 25 percent of the children were informed of their child's diagnosis and given information about it. Less than half of the children had monthly mental health visits or any family intervention. Only 8 percent of children with ADHD or conduct disorder had one or more behavioral therapy sessions, although 54 percent of children with major depression received psychosocial treatment monthly for six to nine months.

While written consent was obtained from 76 percent of primary caregivers before starting drug therapy, only 33 percent received mandated medication information. Thirty percent of the children prescribed psychotropic medication did not have at least one monthly drug monitoring in the first three months of treatment. Less than 25 percent had any indicators that simple medication-related checks like blood pressure, pulse, height, or weight were done, and only a similar proportion recorded any laboratory monitoring of patients.

“In the light of the Food and Drug Administration's recent black-box warning for `close clinical monitoring' of patients on antidepressants, there's a need to improve laboratory and physical observation of these children,” said Julie Magno Zito, Ph.D., an associate professor of pharmacy and psychiatry at the University of Maryland, Baltimore. “But we just don't know if that's being operationalized. The study says it's not being fulfilled.”

The need for monitoring should extend across the board to all psychotropic drugs, not just antidepressants, Zito added.

Only half the children had the requisite patient-protection indicators in their charts. While half were screened for possible physical or sexual abuse, charts for 36 percent of the patients recorded no notice that clinicians had filed a report of suspected abuse.

“Nearly three-quarters of the children with recent suicidal ideation had follow-up care meeting the recommended standards,” said Zima,“ but less than half of the children clinically identified as being at imminent risk of harm to self or others had documentation that treatment in a more restrictive environment was recommended.”

Care for these children may be fragmented, since only 51 percent of the charts indicated links with schools or general health care providers.

The researchers had hypothesized that boys and white children would be more likely to receive proper care than girls and members of ethnic minorities. However, they were surprised to find that “acceptable care did not vary by child gender or ethnicity,” said Zima.

There were geographic variations. Children in wealthier and urban counties had greater documented adherence to treatment principles than did children from poorer and rural counties. Some of that difference, the researchers speculated, may be due to the higher density of other medical and social-service agencies in urban or wealthy districts.

The study relied on chart review, but Zima suggested that future quality of care studies tie these quality variables to patient outcomes and Medicaid administrative claims data.

Much can be done immediately, however, to improve documented care.

“To monitor the safety of children getting medication, clinics should consider using information technologies to support physicians and help them connect with clinical information from the child's primary care doctor,” she said. “They might also add a nurse or nurse practitioner to the clinic team to measure vital signs and to follow up on laboratory study orders at the beginning of every medication visit.”

The study, “Quality of Publicly Funded Outpatient Specialty Mental Health Care for Common Childhood Psychiatric Disorders in California,” can be accessed at<www.jaacap.com> under the February issue. ▪