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Data Points to Behavioral Health as a Growing Challenge for Pediatricians

by Iyue Sung, PhD, Director of athenaResearch

In reviewing a recent survey of over 730 pediatricians conducted by Epocrates, an athenahealth company, we were concerned to note a decline in morale for many pediatricians struggling to keep pace with growing complexity at their practices. The reasons are manifold: increasingly stringent documentation requirements, more demanding parents, and a growing prevalence of complex chronic diseases, to name a few. The athenaResearch team decided to examine and validate the perception of increased complexity by analyzing one particularly interesting phenomenon: the growing rate of behavioral health issues among children.

As noted in earlier posts, the data used in this study is culled from our single-instance, cloud-based software platform (athenaNet), which gives us unique visibility into practice patterns across our national network of over 47,000 providers. For this specific analysis, we followed 431 pediatricians on our network from July 2009 through June 2013. We looked only at visits for patients ages 6-17 because mental health conditions are more common among school age children than among pre-school children (9.6% of visits vs. 2.9% of visits, respectively, between July 2009-June 2013). These children accounted for 2.8 million patient visits over the four-year period and, from these visits, we identified 266,820 encounters with a mental health diagnosis as determined by claims data .

Figure 1 shows the prevalence of increased mental health diagnoses for pediatricians on athenaNet. From July 2009 through June 2010, 8.1% of visits with children ages 6-17 involved a mental health diagnosis. Three years later, that rate increased to 10.5%, a proportional rise of 29%.


Figure 1. Proportion of Visits with Mental Health Diagnosis

This increase was primarily driven by five diagnostic categories: Attention Deficit Hyperactivity Disorder (ADHD) was the most common, accounting for more than half of all mental health diagnoses, followed by anxiety, autism, depression and eating disorders. Since July 2009, the number of ADHD diagnoses increased by almost 8% each year, with other, less common diagnoses increasing at much higher rates. Eating disorder diagnoses, for example, increased 30.5% per year, more than doubling from 2009 to 2013.


Figure 2. Diagnosis and Growth Rate of Select Mental Health

In December 2012, the US Government Accountability Office (GAO) released a study on children’s mental health, based on 2007-2009 data from the Department of Health and Human Services’ Medical Expenditure Panel Survey (MEPS). The GAO found that children covered by Medicaid took psychotropic medications—meaning they had been diagnosed with mental health conditions—at a much higher rate than children covered by private insurance. Looking at recent data from the athenahealth network, we see the same pattern.

With diagnosis rates increasing for both groups, the gap between the publicly and privately insured children persists. An important distinction is that our data is based on clinical diagnoses at the time of visit, while the GAO’s MEPS data relies on parents self-reporting psychotropic medication usage in a survey.


Figure 3. Proportion of Visits by Insurance Type with Mental Health Diagnosis

The GAO also found that boys utilize psychotropic medications at much higher rates than girls. The study speculates that this difference may be driven by a higher prevalence of certain mental health disorders among boys, such as ADHD and schizophrenia, for which psychotropic medications are prescribed. Updated results from our data support this hypothesis (Figure 4): boys are diagnosed with mental illness nearly twice as often as girls, with rates rising for both groups over the last four years.


Figure 4. Proportion of Visits by Gender with Mental Health Diagnosis

Left unanswered is whether this data is attributable to changes in diagnosis patterns or actual changes in prevalence. For example, a
2012 CDC report estimates that diagnoses of autism spectrum disorders rose by more than 20% between 2006 and 2008, but offered no conclusion as to whether changes were due to “better case ascertainment as a result of increases in awareness and access to services, or true increases in prevalence of ASD symptoms.”

A diagnosis-specific view of the data also tells a more nuanced story. While ADHD and autism rates are higher among boys, rates of anxiety, depression, and eating disorders are higher among girls (Figure 5).


Figure 5. Relative Proportion by Gender for Select Mental Health Diagnoses

Whether mental health conditions are becoming more common or the medical community is paying more attention to them (and therefore documenting mental illness more often), behavioral health is becoming a greater component of the pediatrician’s workflow. Although pediatricians will refer many patients to specialists, the frontline for diagnosis is still the pediatric practice.

If you have any questions about this study or suggestions for future athenaResearch studies, please contact us at athenaResearch@athenahealth.com.

As a statistician, Iyue is responsible for methodology, analytic infrastructure, and extracting data-driven insights from the athenahealth patient database. 

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