1. RTI International RTI International is a trade name of Research Triangle Institute. www.rti.org Maternal Depressive Symptoms and Healthcare Expenditures for Children with Chronic Conditions Heather Beil, MPH, PhD RTI International Jada Brooks, PhD, MSPH, RN Linda S. Beeber, PhD, RN, CS University of North Carolina at Chapel Hill 1

2. RTI International Acknowledgements This work was funded by Grant 2T32 NR007091 and Grant 2T32 NR008856 from the National Institute of Nursing Research, NIH 2

3. RTI International Background Healthcare spending for children is highly concentrated among children with chronic health conditions Mothers of children with chronic conditions show higher rates of depression Management of a childs chronic condition requires reliable and accurate assessments and responses to the childs health needs 3

4. RTI International Background Depressive symptoms include cognitive, behavioral, and physical symptoms that accompany an unremitting sad mood Mothers with depressive symptoms may not be able to help children adhere to treatment and may have anxiety that could lead to over use of the ED Previous work on children with asthma found that ED use and expenditures declined after treating mothers for depression 4

5. RTI International Objective The purpose of this study was to assess the relationships between maternal depressive symptoms and their childs healthcare utilization and expenditures in a nationally representative population of children with chronic health conditions. 5

6. RTI International Methods A cross-sectional analysis of the 2004-2009 Medical Expenditure Panel Survey (MEPS) Identified children as chronically ill if met at least one of following conditions: 1) the caregiver reported that the child had a health condition that required ongoing medical care that had or was expected to last longer than one year; 2) the caregiver reported that the child had a functional limitation that had or was expected to last longer than one year; 3) the child had a condition with an ICD-9 code that had been determined to meet the criteria for a chronic condition in previous studies. 6

7. RTI International Methods Dependent variables: Annual number of ED visits, inpatient admissions, preventive office based visits, acute office based visits, outpatient and dental visits and associated expenditures Main explanatory variable: binary variable indicating whether or not the mother reported depressive symptoms Control variables: Demographic information and childs condition severity Negative binomial models for utilization variables Two part models with logistic regression to estimate probability of any expenditure and Generalized Linear Models to estimate amount of expenditure conditional on having any for expenditures 7

8. RTI International Results Among the 54,673 children identified the sample, 13,242, or 24% had a chronic health condition 14% of mothers with CCHC reported depressive symptoms, while 9% of mothers with children without a chronic health condition reported depressive symptoms 8

9. RTI International Survey weighted average number of visits and adjusted Incidence Rate Ratios (IRR) for each category for children with a chronic health condition (N=12,813; weighted flN=17,217,068) Mothers with Depressive symptoms Unadjusted Mean (SE) Mothers without Depressive symptoms Unadjusted Mean (SE)Adjusted IRR95% CI ED visits 0.30** (.03) 0.19 (.007)1.21*(1.01-1.45) Acute office based visits4.15 (.31)3.77 (.15)1.12(0.97-1.25) Preventive visits1.07 (.14)1.09 (.03)1.01(0.86-1.20) Outpatient visits0.23 (.04)0.25 (.02)0.83(0.59-1.16) Inpatient admissions 0.10** (.02) 0.05 (.004)1.78*(1.06-2.98) Dental visits 0.91** (.06)1.34 (.04)0.81*(0.72-0.92) 9

10. RTI International Adjusted expenditures by category for publicly insured children with a chronic condition (N=12,812; weighted N=17,213,543) Any expenditure Expenditure Amount OR95% CIß (SE) Total 0.80(0.61-1.05).06 (.09) ED 1.23*(1.02-1.48)-.12 (.09) Office visit0.90(0.74-1.08).03 (.07) Inpatient hospital1.13(0.94-1.37)-.10 (.23) Outpatient0.99(0.82-1.20)-.16 (.21) Prescription0.95(0.80-1.13).005 (.08) Dental 0.73**(0.62-0.87).03 (.10) 10

11. RTI International Unconditional Predicted Expenditures 11

12. RTI International Discussion Mothers with CCHC were more likely to report depressive symptoms than other mothers Children of mothers with depressive symptoms had higher ED and inpatient utilization, lower dental utilization, and higher predicted expenditures Dental care is number one unmet among children, findings indicate that children of mothers with depressive symptoms may be at higher risk for not getting care The association with higher ED visits could be due to lack of management of disease or an inability to cope with disease at home 12

13. RTI International Limitations Mothers of children in worse health may be more likely to report depressive symptoms, attempted to control for by including measure of condition severity Self-reporting bias Cross-sectional, observational study 13

14. RTI International Policy Implications Healthcare providers treating children with chronic conditions may need to incorporate a more integrated approach to care Both the American Academy of Pediatrics Task Force on the Family and the Bright Futures practice guidelines emphasize the need to support families by addressing maternal health conditions, including depression This study suggests that screening for and treating maternal depressive symptoms may be important when caring for children with chronic conditions 14