Asthma Emergency Department Use – What’s Mental Health Got to Do With It?
In a recently released article in Pediatrics(10.1542/peds.2019-0856), Dr. Naomi Bardach and colleagues examined the relationship between Emergency Department (ED) use in children aged 6-21 years who have asthma, and diagnoses of depression or anxiety or comorbid depression with anxiety. This fascinating study used the Massachusetts All-Payer Claims Database for 2014-2015, and identified 65,342 children with asthma by international classification of disease (ICD-9 and 10) codes, 24.7% of whom had a diagnosis of depression, anxiety or both. The main outcome measure was the rate of asthma-related ED visits/100 child-years, which is a measure EDs use related to asthma developed by the Collaboration for Advancing Pediatric Quality Measurement (CAPQuaM), a center of excellence in the federal Pediatric Quality Measurement Program (PQMP). This measure is the number of ED visits that occur in 100 children with asthma who are in a specific health plan for 1 year.
One beauty of the study is its simplicity of design, and another is the large sample size. The authors carefully walk us through the details and specifics of how asthma and the mental health diagnoses were identified, how and why insurance status was calculated, and how ED visits were counted: this made me realize how many potential pit-falls there are to use of large claims databases! Of note, medication use did not drive classification for either asthma or the mental health diagnoses, although one of the several interesting sensitivity analyses included all children with albuterol pharmacy claims, as a way to add in those with milder asthma. The resounding study result was that depression and anxiety and/or both increased the risk for asthma ED use. Please see the study to understand better both the limitations of this result, as well as why it is likely an underestimate of the influence of mental health diagnoses on asthma ED use.
The authors frame this study by pointing out that work in adults has clearly shown that a diagnosis of depression or anxiety increases asthma-related health care utilization. This pointed me toward thinking about the parents of the children with asthma in this study – might any of them be depressed or anxious, and could this impact asthma care and ED use? Systematic review and meta-analysis has identified that caregivers of children with asthma, as compared to those without asthma, are indeed more likely to be either depressed or anxious. 1 Not surprisingly, parental depression is associated with poorer asthma outcomes for children. 2 In a recent study including adolescents and their parents, parental and child anxiety and depression were initially highly correlated, but even after one year of asthma treatment that clearly improved control for the adolescents, parents remained as anxious and depressed as they were initially. 3 So, where to from here? Certainly the study of Dr. Bardach and colleagues suggests that clinicians should regularly screen and refer for psychological assessment and treatment as a part of medical asthma care, and other relevant literature suggests that we need to find a way to do the same for their parents/caregivers too. As always, we can confidently say more work is needed!
References:
1. Easter G, Sharpe L, Hunt CJ.Systematic Review and Meta-Analysis of Anxious and Depressive Symptoms in Caregivers of Children With Asthma. J Pediatr Psychol. 2015 Aug;40(7):623-32. doi: 10.1093/jpepsy/jsv012.
2. Endrighi R, McQuaid EL, Bartlett YK, Clawson AH, Borrelli B. Parental Depression is Prospectively Associated With Lower Smoking Cessation Rates and Poor Child Asthma Outcomes. Ann Behav Med. 2018;52(3):195–203. doi:10.1093/abm/kax011
3. Licari A, Ciprandi R, Marseglia G, Ciprandi G. Anxiety and Depression in Adolescents with Severe Asthma and in Their Parents: Preliminary Results after 1 Year of Treatment. Behav Sci (Basel). 2019;9(7):78. Published 2019 Jul 13. doi:10.3390/bs9070078
