title: Variations in Mental Health Diagnosis and Prescribing Across Pediatric Primary Care Practices.
abstract: Primary care pediatricians increasingly care for children's mental health problems, but little is known about practice-level variation in diagnosis and psychotropic medication prescribing practices.
  
  
  
  This retrospective review of electronic heath records from 43 US primary care practices included children aged 4 to 18 years with ≥1 office visit from January 1, 2009, to June 30, 2014. We examined variability in diagnosis and psychotropic prescribing across practices using logistic regression with practice fixed effects and evaluated associations of the availability of colocated or community-based mental health providers or the proportion of children in foster care with diagnosis and prescribing using generalized linear mixed models.
  
  
  
  Among 294 748 children, 40 932 (15%) received a mental health diagnosis and 39 695 (14%) were prescribed psychotropic medication. Attention deficit/hyperactivity disorder was most commonly diagnosed (1%-16% per practice). The proportion of children receiving any psychotropic medication (4%-26%) and the proportion receiving ≥2 medication classes (1%-12%) varied across practices. Prescribing of specific medication classes also varied (stimulants, 3%-18%; antidepressants, 1%-12%; α-agonists, 0%-8%; second-generation antipsychotics, 0%-5%). Variability was partially explained by community availability of psychiatrists (significantly higher odds of a diagnosis or prescription when not available) but not by colocation of mental health professionals or percentage of children in foster care.
  
  
  
  The prevalence of mental health diagnosis and psychotropic medication prescribing varies substantially across practices and is only partially explained by psychiatrist availability. Research is needed to better define the causes of variable practice-level diagnosis and prescribing and implications for child mental health outcomes.
authors.affiliation: Center for Pediatric Clinical Effectiveness, PolicyLab.
authors.forename: Stephanie L
authors.initials: SL
authors.lastname: Mayne
authors.affiliation: Departments of Biostatistics and Epidemiology, and.
authors.forename: Michelle E
authors.initials: ME
authors.lastname: Ross
authors.affiliation: Center for Pediatric Clinical Effectiveness, PolicyLab.
authors.forename: Lihai
authors.initials: L
authors.lastname: Song
authors.affiliation: Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois;
authors.forename: Banita
authors.initials: B
authors.lastname: McCarn
authors.affiliation: Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois;
authors.forename: Jennifer
authors.initials: J
authors.lastname: Steffes
authors.affiliation: Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois;
authors.forename: Weiwei
authors.initials: W
authors.lastname: Liu
authors.affiliation: Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia;
authors.forename: Benyamin
authors.initials: B
authors.lastname: Margolis
authors.affiliation: Maternal and Child Health Bureau, Health Resources and Services Administration, US Department of Health and Human Services, Rockville, Maryland;
authors.forename: Romuladus
authors.initials: R
authors.lastname: Azuine
authors.affiliation: Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois;
authors.forename: Edward
authors.initials: E
authors.lastname: Gotlieb
authors.affiliation: Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania;
authors.forename: Robert W
authors.initials: RW
authors.lastname: Grundmeier
authors.affiliation: American Board of Pediatrics, Chapel Hill, North Carolina; and.
authors.forename: Laurel K
authors.initials: LK
authors.lastname: Leslie
authors.affiliation: Departments of Biostatistics and Epidemiology, and.
authors.forename: Russell
authors.initials: R
authors.lastname: Localio
authors.affiliation: Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois; Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vermont.
authors.forename: Richard
authors.initials: R
authors.lastname: Wasserman
authors.affiliation: Center for Pediatric Clinical Effectiveness, PolicyLab, Pediatric Research in Office Settings, American Academy of Pediatrics, Elk Grove Village, Illinois; Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Pediatric Research Consortium, and fiks@email.chop.edu.
authors.forename: Alexander G
authors.initials: AG
authors.lastname: Fiks
mesh_terms: D000293:Adolescent; D001289:Attention Deficit Disorder with Hyperactivity / Q000175:diagnosis; D002648:Child; D002675:Child, Preschool; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D016015:Logistic Models; D008297:Male; D001523:Mental Disorders / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology; D010372:Pediatrics; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D015995:Prevalence; D011320:Primary Health Care; D011570:Psychiatry; D011619:Psychotropic Drugs / Q000627:therapeutic use*; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology; D000078329:Workforce
chemical_list: D011619:Psychotropic Drugs