Jerry L. Rushton

Background. In response to changing reimbursement and other pressures in the health care environment, many physicians have reported the use of alternate coding to substitute for certain clinical diagnoses. However, very little information is available on how physicians who care for children approach diagnosis and coding dilemmas for behavioral and mental disorders, which often present unique additional challenges. Objective. Our study sought to describe the frequency of alternate coding, different approaches to coding, and attitudes toward diagnosis and coding practices by physician specialty. Methods. We conducted a mail survey of 1492 physicians—497 developmental/behavioral pediatricians (DBP), 500 pediatricians (PED), and 495 child and adolescent psychiatrists (PSY). The main outcomes were survey items on frequency of alternate coding (never, rarely, monthly, weekly, daily), use of different coding strategies (use of somatic symptoms, modifiers, and substitution with other terms), and attitudes on coding practices (Likert scales of agreement). We analyzed outcomes by physician specialty and demographics using Pearson’s χ² and multivariate logistic regression. Results. Overall response rate was 62% (787 of 1269 eligible physicians). The majority of physicians had used an alternate code (DBP 83%, PED 68%, PSY 58%), and many respondents reported monthly-daily alternate coding (DBP 60%, PED 36%, PSY 27%). Physicians used multiple approaches to diagnosis and a variety of coding options, which varied by physician specialty. Financial issues were commonly cited reasons for alternate coding—both to obtain patient services and to receive physician reimbursement. However, challenges of diagnostic classification and coding subthreshold symptoms were cited as frequently as reimbursement issues. Stigmatization, confidentiality, and parental acceptance were mentioned, but reported less frequently. Very few practices and providers have organized administrative methods of alternate coding (26%) or receive feedback on denied claims (46%). Most physicians believe that alternate coding is justified in the present system; however, some physicians expressed concerns that these practices may contribute to stigmatization or lead to improper management decisions. Conclusions. Alternate coding is commonly reported; however, approaches to diagnostic coding vary by provider specialty. Reimbursement issues are important, but other challenges in diagnosis and classification hold special relevance to children with behavioral and mental disorders. There seems to be a great need to reconsider the separate goals and uses of clinical diagnosis and administrative coding. Additional study is needed to assess how reported coding practices may affect administrative data, patient care, and health care economics.

Objectives To examine primary care provider referral patterns for patients with psychosocial problems and to understand the factors that influence whether a mental health referral is made. Design Secondary analysis of the Child Behavior Study data collected during 1994-1997 from background survey of providers, visit survey of providers and parents, and follow-up survey of parents. Setting Two hundred six primary care offices in the United States, Canada, and Puerto Rico. Patients Four thousand twelve of 21 150 patients aged 4 to 15 years in the Child Behavior Study with a clinician-identified psychosocial problem. Main Outcome Measures Referral for psychosocial problem at index visit and reported follow-up with mental health care provider within 6 months. Results Six hundred fifty (16%) of 4012 patients with psychosocial problems were referred at the initial visit. In multivariate analysis, significant factors associated with likelihood of referral included patient factors (severity, type of problem, academic difficulties, prior mental health service use) and family factors (mental health referral of parent); however, none of the provider factors were significant. Clinicians reported frequent barriers to referral and mental health services in the general background survey; however, these factors were rarely reported as influences on individual management decisions. Only 61% of referred families reported that their child saw a mental health care provider in the 6-month period after the initial primary care referral. Conclusions Most psychosocial problems are initially managed in primary care without referral. However, referral is an important component of care for patients with severe problems, and many families are not effectively engaged in mental health services, even after a referral is made.

Background Presciption trends have key implications for costs, outcomes, and research, yet few data exist on pediatric selective serotonin reuptake inhibitor (SSRI) trends and associations with stimulant trends. Objective To describe prescription trends for stimulants, SSRIs, and combination prescriptions by age, sex, and race. Methods Retrospective population-based analysis of North Carolina Medicaid prescription claims files. Participants North Carolina Medicaid recipients, 1992 through 1998, aged 1 to 19 years. The population ranged from 342 333 children in 1992 to 581 088 in 1998. Main Outcome Measures Annual number of prescriptions, patients filling a prescription claim, and prescription prevalence for stimulants and SSRIs. Results The number of children and adolescents who received stimulants increased from 6407 (24 584 claims) in 1992 to 27 951 (135 057 claims) in 1998. The number of SSRI recipients increased from 510 children (1326 claims) in 1992 to 6984 children (25 392 claims) in 1998. Prescription prevalence in school-aged children 6 to 14 years increased from 4.4% to 9.5% for stimulants during the study period, and from 0.2% to 1.5% for SSRIs. In 1998, stimulant prescription prevalence was highest for white school-aged males (18.3%) vs black females (3.4%) and SSRI prescription prevalence was highest for white school-aged males (2.8%) vs black females (0.6%). Combination pharmacotherapy also increased during 1992 through 1998. Conclusions Prevalence of stimulant and SSRI medications has increased during the 1990s, with prescription prevalence in North Carolina Medicaid youth higher than previously reported. Age, sex, and racial differences are apparent and call for further attention. Combination pharmacotherapy also has growing importance.

Objectives. Selective serotonin reuptake inhibitor (SSRI) prescriptions for children and adolescents have increased greatly in recent years despite a paucity of demonstrated safety and efficacy data and a lack of clear guidelines for use. Our study sought to describe family physician and pediatrician SSRI prescribing patterns for children and adolescents, identify influences on SSRI prescription variations, and describe the use of SSRI within the overall management of depression and other mental disorders in primary care. Design. A survey was mailed to all 596 active North Carolina general pediatricians and a random sample of 557 family physicians in primary care practice. Family physicians who did not see children in their practice were excluded. The survey instrument consisted of a 4-page questionnaire. Survey items included physician demographics, practice characteristics, general management, volume of pediatric patients with depressive symptoms, prescription of SSRIs for depression and other diagnoses, and potential influences on SSRI prescribing practices. The main outcomes were self-reported physician prescription of SSRIs for children and adolescents. Results were analyzed using χ² comparisons and logistic regression. Results. The overall response rate was 66% (55% family physicians and 76% pediatricians). Of the physicians, 72% had prescribed an SSRI for a child or adolescent. Depression was the most common reason for prescribing an SSRI; over two thirds of respondents had prescribed an SSRI for depression in a child 18 years of age or younger. Over half of the physicians reported they had prescribed an SSRI for a diagnosis other than depression in a child 18 years of age or younger. Attention-deficit/hyperactivity disorder was the most frequent use cited other than depression, followed by obsessive–compulsive disorder, aggression, eating disorders, and enuresis. Primary care physicians prescribed SSRIs for adolescents more commonly than for younger children. Only 6% of the respondents had ever prescribed an SSRI for a child younger than 6 years of age. In terms of SSRI prescriptions written for depression in the last 6 months, 32% of the physicians had recently prescribed SSRIs for adolescent patients and 6% for patients younger than 12 years of age. Family physicians were more likely than pediatricians to have recently prescribed SSRIs for adolescent patients (41% vs 26%), but there was no difference in recent SSRI prescriptions for children <12 years of age by physician specialty (4% vs 6%). Prescription of SSRIs was not associated with decreased use of counseling for treatment of depression, but prescription of SSRIs was associated with decreased use of referrals (63% vs 74%). There was no difference in the use of counseling between family physicians and pediatricians (61% vs 59%). However, pediatricians were more likely to use referrals in their usual approach to depression (77% vs 48%) compared with family physicians. More family physicians had prescribed SSRIs for pediatric patients compared with pediatricians (91% vs 58%), and more family physicians had prescribed SSRIs in combination with other psychotropic medications (54% vs 31%). For the majority of respondents, SSRI prescriptions constituted most of the medications used to treat childhood depression (75% of family physicians vs 61% of pediatricians). Family physicians were more likely to report a belief in the safety (63% vs 48%) and effectiveness (40% vs 32%) of SSRIs. Only 8% of physicians reported adequate training in the treatment of childhood depression and just 16% were comfortable with the treatment of depression. There were no specialty differences in training for the treatment of childhood depression; however, more family physicians than pediatricians agreed that they were comfortable with the management of childhood depression (22% vs 11%). In logistic regression analysis of SSRI prescriptions controlling for physician demographics and practice settings, physicians who were more likely to have prescribed an SSRI for a pediatric patient included: family physicians (odds ratio [OR]: 6.5; 95% confidence interval [CI]: 3.7–11.4), physicians who had limited referral availability (OR: 5.9; 95% CI: 2.2–15.7), physicians comfortable with management of depression (OR: 5.4; 95% CI: 1.8–15.8), and physicians who believed in SSRI safety (OR: 2.4; 95% CI: 1.4–3.9) and effectiveness (OR: 2.9; 95% CI: 1.6–5.3). Factors that were not associated with SSRI prescription rates included parental pressures or fears, constraints of managed care, training experience, year of residency, gender, age, practice type, percentage of Medicaid patients, and percentage of managed care patients. Conclusions. Many primary care physicians, especially family physicians, prescribe SSRIs for children and adolescents. SSRIs have become the primary care physician9s medication of choice for depressed children and adolescents, and SSRIs are also used for other pediatric diagnoses. Despite concerns of inappropriate uses, a number of primary care practices seem to be reasonable: depression is the most common diagnosis cited, adolescents receive SSRIs more often than younger children, and SSRI use does not seem to be a substitute for counseling. However, it is not clear whether adult treatment practices and preliminary pediatric clinical trials generalize to children and adolescents in primary care. Future pediatric studies need to examine the use of SSRIs to treat attention-deficit/hyperactivity disorder and other diagnoses, safety of combination pharmacotherapy, and outcomes for children treated in primary care. In addition to considerations of potential overuse or inappropriate use of SSRIs, we must conversely evaluate issues of underdiagnosis and undertreatment of mental disorders. The lack of training and comfort of care of pediatric depression and mental illnesses cannot be overlooked. Training and continuing education must improve and change as new pharmacotherapies emerge. Finally, physician specialty differences must be explored further to determine whether differences in physician SSRI prescription practices translate into different health outcomes for children and adolescents with mental illnesses.

Objective.: To provide a self-described assessment of pediatricians' and family physicians' management of childhood depression.Design.: Mail survey of 595 general pediatricians and 557 family physicians in North Carolina.Results.: The response rate was 66%. Most primary care physicians used referral (65%) and counseling (61%) for management of childhood depression. Family physicians used medications more commonly (18% vs 9%), and pediatricians referred patients more commonly (77% vs 48%). In logistic regression analysis, physicians comfortable with management of depression (odds ratio [OR], 4.8: 2.7–8.4), physicians who believed that antidepressants are more effective than counseling (OR, 2.6: 1.4–4.8), and family physicians (OR, 2.2: 1.9–4.1) were more likely to have used medications for childhood depression.Conclusions.: Most primary care physicians refer pediatric patients with depression; however, practice patterns vary by specialty and other factors. Future studies must consider the role of primary care and evaluate how interspecialty variations affect costs and outcomes of childhood depression.