Family report compared to clinician-documented diagnoses for psychiatric conditions among hospitalized children
BACKGROUND
Psychiatric comorbidity is common in pediatric medical and surgical hospitalizations and is associated with worse hospital outcomes. Integrating medical or surgical and psychiatric hospital care depends on accurate estimates of which hospitalized children have psychiatric comorbidity.
OBJECTIVE
We conducted a study to determine agreement of family report (FR) and clinician documentation (CD) identification of psychiatric diagnoses in hospitalized children.
DESIGN AND SETTING
This was a cross-sectional study at a tertiary-care children’s hospital.
PATIENTS
The patients were children and adolescents (age, 4-21 years) who were hospitalized for medical or surgical indications.
MEASUREMENTS
Psychiatric diagnoses were identified from structured interviews (FR) and from inpatient notes and International Classification of Diseases codes in medical records (CD). We compared estimates of point prevalence of any comorbid psychiatric diagnosis using each method, and estimated FR–CD agreement in identifying psychiatric comorbidity in hospitalized children.
RESULTS
Of 119 study patients, 26 (22%; 95% confidence interval [CI], 14%-29%) had a psychiatric comorbidity identified by FR, 30 (25%; 95% CI, 17%-34%) had it identified by CD, and 37 (23%-40%) had it identified by FR or CD. Agreement between FR and CD was low overall (κ = .46; 95% CI, .27-.66), highest for attention-deficit/hyperactivity disorder (κ = .78; 95% CI, .59-.97), and lowest for anxiety disorders (κ = .11; 95% CI, –.16 to .56).
CONCLUSIONS
Current methods may underestimate the prevalence of psychiatric conditions in hospitalized children. Information from multiple sources may be needed to develop accurate estimates of the scope of the population in need of services so that mental health resources can be appropriately allocated. Journal of Hospital Medicine 2017;12. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
Psychiatric conditions affect 1 in 5 children,1,2 and having a comorbid psychiatric condition is associated with worse outcomes in children hospitalized for medical or surgical indications.3-7 Although little is known about interventions for improving outcomes for hospitalized children with psychiatric conditions,8 several interventions that integrate medical and psychiatric care are known to improve ambulatory patient outcomes.9-14 The success of initiatives that test whether integrated medical and psychiatric care models can improve pediatric hospital outcomes depends on reliable identification of comorbid psychiatric conditions and family and clinician having a shared understanding of a patient’s psychiatric diagnoses.
Mental health care system fragmentation, stigma, and privacy issues15-20 may contribute to clinical teams and families having disparate views of psychiatric comorbidities. Evidence suggests that hospital clinicians caring for pediatric medical and surgical inpatients are often unaware of a psychiatric condition that has been diagnosed or managed in the ambulatory setting,3,6 even in cases in which the patient and family are aware of the diagnosis. Conversely, for other patients, clinicians may be aware of a psychiatric diagnosis, but patient and family may not share that understanding or reliably report a psychiatric diagnosis.21-23 Although hospitalization may not be the ideal setting for identifying a new psychiatric diagnosis, given the short-term relationship between patient and clinical care team, addressing and managing a psychiatric comorbidity that is known to family or clinician are important elements of patient-centered hospital care.
The success of interventions in improving hospital outcomes for hospitalized children with psychiatric comorbidity depends on patients, families, and clinicians having a shared understanding of which patients have psychiatric conditions, and on accurate estimates of the scope of the population in need of psychiatric care during pediatric hospitalization.
We conducted a study to compare estimates of point prevalence of psychiatric comorbidity identified by family report (FR) or clinician documentation (CD) and to determine the degree of FR–CD agreement regarding the presence of psychiatric comorbidity in hospitalized children.
METHODS
We estimated point prevalence and determined FR–CD agreement regarding diagnosed psychiatric comorbidities in a cross-sectional sample of pediatric medical and surgical hospitalizations at Children’s Hospital of Philadelphia (CHOP). CHOP is a free-standing 535-bed children’s hospital that serves as a community hospital for the city of Philadelphia; a regional referral center for eastern Pennsylvania, Delaware, and southern New Jersey; and a national and international quaternary referral center. This study was approved by CHOP’s institutional review board.
