Psychosomatics 41:128-133, April 2000
© 2000 The Academy of Psychosomatic Medicine
Child and Adolescent Psychiatry in General Children's Hospitals
A Survey of Chairs of Psychiatry
John V. Campo, M.D., ,
Richard S. Kingsley, M.D.,
Jeffrey Bridge, B.S., , and
David Mrazek, M.D.
Received March 19, 1999; revised June 17, 1999; accepted July 6, 1999. From the University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic (JB) and the Behavioral Science Division, Children's Hospital of Pittsburgh, Pittsburgh, PA (JC); the Division of Behavioral Health, The Alfred I. duPont Hospital for Children, Wilmington, DE (RK); and the Department of Psychiatry and Behavioral Sciences, The George Washington University School of Medicine, Washington, DC (DM). Address reprint requests to Dr. Campo, Director, Behavioral Science Division, Children's Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, PA 15213; e-mail: campojv{at}msx.upmc.edu
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ABSTRACT
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This article characterizes the academic, administrative, clinical service, and fiscal characteristics of departments of psychiatry in traditional children's hospitals to determine the characteristics of fiscally successful programs. A survey of chairs of psychiatry from short-term general children's hospitals was conducted based on 38 questions addressing the descriptive characteristics of their respective departments. The characteristics of psychiatry programs identified as fiscally successful were compared to those of programs that required subsidy. Nine of 45 eligible children's hospitals (20%) did not have a department or section of psychiatry, and surveys were returned by 35 of 36 department chairs (97% response). Considerable variation exists in the academic, administrative, clinical services, and fiscal characteristics of programs, although over half are operating at a deficit. Fiscal success was associated with availability of inpatient and intermediate levels of psychiatric care, better integration of the psychiatry program within the children's hospital, and adequate fiscal information being provided to the psychiatry chair. Additional research regarding the potential of psychiatric services to generate clinical success and cost savings is warranted. Pediatric health care professionals and third-party payers should be educated regarding the relevance of psychiatric services within children's hospitals and in physically ill children.
Key Words: Child and Adolescent Psychiatry
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INTRODUCTION
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Emotional and behavioral difficulties commonly first present in pediatric medical settings, often with medically unexplained physical symptoms,1 and affected children may be particularly high users of pediatric health services.2 Chronic physical illness appears to be a significant risk factor for emotional and behavioral difficulties,3,4 and emotional, behavioral, and family difficulties can negatively affect the course of physical disease as a consequence of negatively influencing health maintenance and compliance behaviors, or by a direct physiologic effect on the disease process itself.5,6 Approximately 20% of children suffer from minor chronic disorders such as ear infections, asthma, and allergic disorders, and an additional 10% suffer from a serious chronic physical illness, with the vast majority of children with complex chronic health conditions being cared for within children's hospitals or general hospitals with postgraduate pediatric residency training programs.7
Children's hospitals are looked to by parents and health care professionals as resources for expertise in all aspects of pediatric health care, including emotional and behavioral health. Unfortunately, although children's hospitals do appear to be a major source of behavioral health service delivery in some locations, systematic descriptions of psychiatric services in U.S. children's hospitals are lacking. This is a particularly relevant issue at a time when evidence for the relevance of psychiatric and behavioral health interventions in augmenting the effectiveness of traditional health care and containing health care expenditures has been growing.6
The formation of the Association of Chairs of Psychiatry at Children's Hospitals (ACOPACH) in Philadelphia in 1996 catalyzed efforts to examine the state of psychiatric services in children's hospitals. ACOPACH members agreed to pursue a survey of chairs of psychiatry at traditional children's hospitals in the U.S. with two primary aims. First, we wished to learn more about the descriptive characteristics of psychiatry departments or sections within traditional children's hospitals, including academic, administrative, clinical service, and fiscal characteristics. Second, we wished to learn whether there were characteristics that distinguished psychiatry sections known to be fiscally successful from those known to be operating in deficit.
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METHODS
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A survey was developed consisting of 38 questions addressing the academic, administrative, clinical service, and fiscal characteristics of the psychiatry sections of the 45 children's hospitals capable of being classified as short-term general children's hospitals (classification 50-S) by the National Association of Children's Hospitals and Related Institutions (NACHRI). Of these, 34 questions required a "yes/no" answer, and 4 required a numeric response. Surveys were mailed to known chairs of psychiatry or the equivalent titular director of psychiatric services. In instances where the name of the chair was not known, telephone calls were made to the hospital switchboard, followed by the office of the medical director and the chief administrator to determine how to contact the chair. Surprisingly, a small number of hospitals (9) did not have a department or even a section of psychiatry. Surveys were mailed to the 36 institutions with identified psychiatry programs. In those children's hospitals lacking a department or section of psychiatry, the medical director's or administrator's office was questioned regarding what services were available to address the behavioral health needs of children cared for within the institution. Follow-up phone calls were made and faxed reminders sent if surveys were not returned in 1 month.
Descriptive statistics were used in examining survey results addressing program characteristics. Mean, standard deviation (SD), and median values are reported where relevant. The characteristics of psychiatry programs identified as fiscally successful were compared to those of programs that required subsidy using standard univariate statistics such as chi-square and Fisher's exact test (FET).
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RESULTS
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Sample Characteristics
Of the total number of 45 50-S children's hospitals surveyed, 36 (80%) had an identified department or section of psychiatry, whereas 9 (20%) did not. Regarding the 9 children's hospitals without psychiatry departments, 1 hospital had access to psychiatric services within the section of developmental and behavioral pediatrics. The remaining 8 children's hospitals relied exclusively on psychology, with inadequate psychiatric emergency coverage or appropriate psychotropic medication management capabilities. The characteristics of psychiatry programs did not appear to be influenced by the presence or absence of an established section of developmental behavioral pediatrics. Surveys were returned by 35 of 36 psychiatry section chiefs (97%). The mean number of beds in surveyed children's hospitals was 229 (SD=70; median 225).
Academics
Medical school or university affiliations were present in 33 (94%) of the responding programs, and 15 of the chairs (43%) also served as chief of the medical school's division of child and adolescent psychiatry (see Table 1). Child and adolescent psychiatry trainees routinely rotated on 28 (80%) of the psychiatry services. All of the children's hospitals surveyed offered training programs in pediatrics, and pediatric residents routinely obtained training within the psychiatry section in 17 (49%) of the programs. General psychiatry trainees received training in 22 programs (63%), and two programs (6%) offered a triple-board program for certification in pediatrics, psychiatry, and child and adolescent psychiatry.
Administrative
The faculty and staff of the psychiatry department or section were employed by the affiliated university, medical school, or another entity in 16 of 34 programs (47%), and by the children's hospital in 12 programs (35%). An additional 6 programs (18%) reported that faculty were employed by the affiliated university or medical school department of psychiatry, while the section staff were employed by the children's hospital (see Table 2).
Nine chairs (26%) reported that all behavioral health services within the children's hospital reported directly to them and were contained within their department. Psychologists reported to the psychiatry chair in 21 programs (60%), social workers in 17 (49%), child-life workers in 2 (6%), and nurses in 13 (37%). Most chairs had multiple reporting lines themselves, with 19 (54%) reporting to the hospital chief executive officer, 20 (57%) to another hospital administrator, 24 (69%) to the chair of the department of psychiatry in the medical school, 12 (34%) to the chair of pediatrics, and 7 (20%) to the chief of the division of child and adolescent psychiatry.
The mean number of full-time equivalent positions (FTEs) reporting to the psychiatry chair or section chief was 18.5 (SD=31.1), with a median of 5.5, reflecting a wide variation in program size. Approximately 60% of the psychiatry departments (19 of the 32 reporting FTE data) accounted for less than 10 FTEs each, with 25% (8) claiming 10–20 FTEs, 9% (3) reporting between 20 and 100 FTEs, and 6% (2) reporting more than 100 FTEs (see Table 2). The largest programs offered a more comprehensive behavioral health service line and included psychiatric nursing within the department.
Separate sections of psychology were reported in 15 programs (43%), social work in 28 (82%), and child life in 26 (79%). Sections of developmental-behavioral pediatrics (DBP) were reported to exist in 21 (60%) of the children's hospitals surveyed, with collaborative relations between psychiatry and DBP reported by 12 programs (48%), respectful relations by 10 (40%), and competitive or adversarial relations by three (12%).
Clinical Services
Inpatient C-L psychiatry services were offered by all the responding programs, with a mean of 7.2 (SD=6.1) and a median of 5.0 new consultations per week (see Table 3). Thirty-two programs (91%) offered around-the-clock emergency psychiatric consultation services for children cared for within the children's hospital.
Outpatient C-L psychiatry services and outpatient psychiatric treatment services were available in 33 programs (94%). Programs averaged 7.2 new outpatient consultations per week (SD 8.4), with a median of 5.0. Outpatient psychiatric treatment services were offered in a variety of locations, including the children's hospital (74%), subspecialty clinics (47%), hospital satellites (47%), and primary care sites (29%). Nearly half of the programs (46%) offered presurgical psychiatric screening evaluations, although only one-third (37%) offered formal psychological preparation for surgery. The psychiatry section was formally involved in a specialized pain management service in only 10 programs (29%), and biofeedback was offered as a treatment modality by only 9 programs (26%).
Inpatient psychiatric treatment services were found in 18 programs (51%), with the majority of inpatient psychiatric units (78%) being best characterized as general child and adolescent psychiatry inpatient units. Most units were considered capable of managing patients with considerable physical illness on a case-by-case basis. Four programs (22%) claimed to have specialized pediatric medical psychiatry units. The mean number of beds per program was 18.1 (SD=9.6; median: 16.0), with an average length of stay of 10.9 days (SD=4.5; median: 9.0) and an average percent occupancy over the previous year of 74% (SD=15.2; median: 75%).
Psychiatric partial hospitalization services were available in 15 programs (44%), with 11 programs (32%) also reporting specialized medical day treatment services and 3 programs (9%) reporting the availability of residential treatment services.
Fiscal Characteristics
Each psychiatry chair was asked to rate the fiscal status of his or her program, with 29 (83%) providing fiscal ratings and 6 (17%) reporting they did not have access to financial reports. Of the programs providing ratings, just over one-half reported operating at a deficit (15 programs, or 52%), with 8 (28%) describing their program as profitable and 6 (21%) as cost-neutral (see Table 4). Twenty of 35 chairs (59%) acknowledged responsibility for managing their section's budget, and approximately three-fourths of them regularly received systematic information on costs, billable hours, charges, and payments/revenues.
In an effort to explore potential correlates of fiscal success, descriptive, academic, administrative, clinical, and fiscal differences among the 14 programs described as profitable or cost-neutral were compared to the 15 programs in deficit (see Table 4). Despite the small size of the groups, some significant differences and trends did emerge. Fiscally successful programs were significantly more likely to provide inpatient psychiatric treatment, partial hospitalization services, and medical day treatment services. The successful psychiatry programs were also significantly more likely to report that pediatric residents routinely rotated on the service and that there was an organized section of social work within the hospital. Fiscally successful programs also appeared to be more likely to offer outpatient psychiatric services within the primary care setting (P=0.11). Chairs of fiscally successful psychiatry sections received regular information on the status of payments and revenues 93% of the time compared to 60% in financially unsuccessful programs (P=0.08).
Fiscal aspects of individual types of service were also examined. Approximately two-thirds of inpatient C-L psychiatry services were reported to not fully cover their costs (20 of 29 programs, or 69%), with just less than one-third considered profitable or cost-neutral. Outpatient C-L psychiatry services were in deficit in 16 of 27 programs (59%) and were profitable or cost-neutral in 11 (41%). Outpatient psychiatric treatment services were rated as profitable or cost-neutral by 16 of 28 chairs (57%), with 12 (43%) reporting them as in deficit. Inpatient psychiatric treatment services were by far the most likely to be considered profitable or cost-neutral, with 10 of 16 reporting programs (63%) described as profitable, 5 (31%) as cost-neutral, and only 1 (6%) as being in deficit. Psychiatric partial hospitalization services were described as profitable or cost-neutral in two-thirds of the 12 programs providing ratings, with one-third rated as losing money. Medical day treatment services were rated as profitable or cost-neutral in 5 of 9 programs (56%) and as a financial loss in 4 (44%).
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DISCUSSION
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Approximately 1 in 5 short-term general U.S. children's hospitals do not provide accessible pediatric psychiatry services. This represents a serious breach of appropriate service delivery, given the intimate relationship between physical and behavioral health and well-being. There is increasing evidence that psychiatric disorders can have a negative impact on physical health and well-being.5 For example, there is evidence that depressive illness confers a significant risk for the development of retinopathy in individuals with childhood-onset, insulin-dependent diabetes mellitus independent of glycemic control, raising questions as to whether timely treatment of depression in diabetic children could prevent or delay the development of retinopathy.8 Psychopharmacologic interventions are especially relevant in modern behavioral health practice, and the complicated medical histories and complex medication regimens that are commonplace in a children's hospital increase the risk of potentially serious pharmacodynamic and pharmacokinetic drug interactions, highlighting the importance of psychopharmacologic expertise being available in tertiary pediatric settings. Pediatric psychiatrists can provide needed psychopharmacologic consultation and education for pediatric health care professionals, as well as ongoing medication management for children and adolescents with particularly complicated regimens or refractory problems. Education is needed for administrators and other health care professionals regarding the medical training background of child and adolescent psychiatrists, their experience with a full range of psychotherapeutic and psychopharmacologic interventions, and the integrative perspective they are capable of bringing to pediatric health care and the delivery of behavioral health services in such settings.
At least one-half of psychiatry programs in general children's hospitals are reported to operate at a deficit and require subsidy. The services most commonly requested from and provided by departments of psychiatry in children's hospitals are inpatient and outpatient C-L psychiatry services. Remarkably, C-L services are in deficit in the vast majority of programs despite a growing body of literature highlighting the importance of psychiatric consultation in improving efficiency of service delivery and reducing health care expenditures in a number of different physically ill populations.9–13 Psychiatric disorders have been demonstrated to be a robust predictor of increased length of hospital stay and medical readmission rate in adult medicine.14 Children who present with medically unexplained physical symptoms are more likely to suffer from emotional and behavioral difficulties and be high utilizers of both health and mental health services,15 and children with parent-reported behavioral difficulties make more frequent visits to their doctors.2 Professionals involved in the care of children and adolescents requiring psychiatric consultation in pediatric medical settings may need to advocate for the importance and relevance of these services to ensure their continued availability through subsidy by more profitable components of the service delivery system. Additional research exploring the clinical cost-saving benefits and alternative sources of reimbursement for pediatric C-L psychiatric services is clearly warranted.
Correlates of fiscal success include the availability of inpatient psychiatric treatment and intermediate levels of care, with successful programs offering a comprehensive array of services, including psychiatric services in primary care settings. Unfortunately, less than half of general children's hospitals offer comprehensive psychiatric services, and the majority of psychiatry programs in children's hospitals are still only small-to-moderate in size. Although the appropriate size should be based on the scope of practice, more comprehensive psychiatric services appear to correlate with both fiscal and clinical success. Others have reported that availability of comprehensive pediatric psychiatric services allows for greater financial stability, economies of scale, and flexibility in addressing the needs of patients and families, as well as providing a critical mass of consultants and teachers for pediatric, psychiatric, and other behavioral health trainees.16
Chairs of fiscally successful programs are more likely to have access to reliable information on the nature of revenues for their department, but approximately one in five psychiatry chairs do not have reliable information regarding their section's fiscal status. Administrators should understand the importance of providing relevant budgetary information, particularly regarding revenues, to psychiatry chairs.
Interestingly, being part of a children's hospital with an identified department of social work and the regular involvement of pediatric trainees on the psychiatry service also correlate with fiscal success. This may suggest that children's hospitals where there is a broad institutional interest and commitment to a vision of pediatric care based on the biopsychosocial model are more likely to offer comprehensive, integrated, and fiscally successful psychiatric services. Unfortunately, only one-quarter of psychiatry chairs report that all behavioral health professionals in the children's hospital are fully integrated in a single department or section, and the majority of psychiatry programs still do not offer a full range of behavioral medicine services such as biofeedback or specialized pain management clinics, perhaps reflecting difficulties associated with reimbursement for such services and for preventive services in general. Together, our findings suggest that there may be an optimal configuration of psychiatric and behavioral health services that will increase the likelihood of fiscal success, and the ability of a children's hospital to generate creative and effective ways to organize multidisciplinary teams of professionals around a mission based on the biopsychosocial model may prove critical to the ultimate success or failure of these programs.
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ACKNOWLEDGMENTS
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Dr. Campo was supported in part by National Institute of Mental Health Grant MH55123, Child and Adolescent Developmental Psychopathology Research Center for Early Onset Affective and Anxiety Disorders.
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REFERENCES
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- Kovacs M, Mukerji P, Drash A, et al: Biomedical and psychiatric risk factors for retinopathy among children with IDDM. Diabetes Care 1995; 18:1592–1599
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ABSTRACT
INTRODUCTION
