Impact and Cost-Effectiveness of Integrated Psychology Services in a Pediatric Endocrinology Clinic

Integrated psychological care in pediatric hospital settings for children with complex chronic illness and their families: a systematic review

OBJECTIVE

To synthesize and critically evaluate evidence on the effectiveness of integrated psychological care models for children with complex chronic illness within pediatric hospital settings and provide recommendations for successful implementation.

DESIGN

Six electronic databases (Medline, Cochrane, Embase, PsycINFO, Scopus, CINAHL) were systematically searched for English language studies including families of children aged 0-17 years with complex chronic illness. Eligible studies reported on psychology or neuropsychology screening, assessment, intervention, or services provided within a pediatric hospital setting.

RESULTS

Fifteen studies were identified for review; nine assessed a psychological service, five examined psychosocial screening, and one examined a neuropsychology service. Three studies demonstrated the effectiveness of integrated psychological services in improving child or parent physical, psychological, or behavioral health outcomes. Uptake of psychosocial screening was high (84-96%), but only 25-37% of children or families identified as 'at-risk' engaged with on-site psychology services. Integrated psychological services offering consultations at the same time and location as the child's medical visit reported the highest rates of uptake (77-100%).

CONCLUSIONS

The available evidence supports co-location of child medical and psychological services. A more consistent and comprehensive approach to the assessment of patient- and caregiver-reported outcomes and implementation effectiveness is recommended.

Increasing access to psychological services within pediatric rheumatology care

BACKGROUND

Given the impact of psychological factors on rheumatic disease, pediatric psychologists serve a vital role in promoting quality of life and managing common problems among youth with rheumatic disease. The aim of this project was to increase access to psychological services among youth with rheumatic disease at a children's hospital.

METHODS

A quality improvement (QI) team identified key drivers and interventions aimed to increase access to psychological services for youth with rheumatic disease. Data was collected for a 6-month baseline period and 4-year intervention period. We applied the Plan-Do-Study Act method of QI and the American Society for Quality criteria to adjust the center line and control limits.

RESULTS

There were two statistically significant center line shifts in the number of patients seen by psychology and one statistically significant shift in referrals to psychology over time with applied stepwise interventions. Patients seen by a psychologist increased by 3,173% from a baseline average of 1.8 to 59.9 patients seen per month (p < 0.03). Psychology referrals increased by 48% from a baseline average of 9.85 to 14.58 referrals per month over the intervention period (p < .01).

CONCLUSIONS

Youth with rheumatic disease received increased access to mental health treatment when psychological services were imbedded within rheumatology care. Psychology referrals also increased significantly, suggesting that psychology integration within a medical clinic can increase identification of needs. Results suggest that psychology integration into rheumatology care may increase access to mental health treatment and identification of psychological needs in this at-risk population.

Psychological Care for Children and Adolescents with Diabetes and Patient Outcomes: Results from the International Pediatric Registry SWEET

Background

Easy accessibility of psychosocial care is recommended for children and adolescents with type 1 diabetes (T1D) and their families.

Objective

The study aimed to evaluate the availability of psychological care and its associations with glycemic control in centers from the multinational SWEET (Better control in Pediatric and Adolescent diabeteS: Working to crEate CEnTers of Reference) registry.

Subjects

Centers participating in SWEET (n = 112) were invited to complete a structured online survey, designed for the study, regarding their psychology service.

Methods

Linear/logistic regression models adjusted for several confounders were used to determine the patient's HbA1c (mmol/mol) and odds ratios (ORs) for diabetic ketoacidosis (DKA) and severe hypoglycemia (SH) related to survey responses.

Results

76 (68%) centers with relevant data in the SWEET database responded to the survey. Psychological services were provided in 89% of the centers. The availability of psychological service in centers was associated with a slightly lower HbA1c of the patients (72 (62-82) vs. 67 (57-78) mmol/mol, p = 0.004) and significantly lower odds for DKA (1.8 (1.1-2.9), p = 0.027).

Conclusions

Most centers from the SWEET registry offered some form of structured psychological care, consistent with the recommendations of easy access to psychosocial care for children and adolescents with T1D and their families. The main benefit of this psychological care appears to be in the incidence of DKA between centers. The study data also continues to emphasize the importance of treatment targets in shaping the outcomes of pediatric diabetes care. These findings should inform health-service planners and the diabetes community of the importance of mental healthcare in multidisciplinary diabetes teams.

Psychosocial Staffing and Implementation of the International Society for Pediatric and Adolescent Diabetes Psychological Care Guidelines in U.S. Pediatric Diabetes Clinics

Background

Few studies have examined the implementation of the International Society for Pediatric and Adolescent Diabetes (ISPAD) Clinical Practice Consensus Guidelines for the Psychological Care of Children and Adolescents with Type 1 Diabetes.

Objective

To collect benchmark data on psychosocial staffing and implementation of the ISPAD guidelines across U.S. pediatric diabetes clinics.

Methods

Medical (n = 95; 77 endocrinologists and 18 advance practice providers) and psychosocial (n = 86; 43 social workers and 43 psychologists) providers from 98 of 115 contacted clinics completed an online survey (85% response rate). Providers reported the number of psychosocial staff and rated the adequacy of psychosocial staffing, quality of psychosocial care, and adherence to the ISPAD guidelines in their clinics. χ2 Tests and ANOVA were used to examine differences across clinic size and across medical and psychosocial providers.

Results

Clinics averaged a total of ∼4 hours per week of psychosocial provider time per 100 patients with type 1 diabetes. Only 27% of providers agreed that psychosocial staffing was adequate, and 35% described their psychosocial care as comprehensive. Implementation of the ISPAD guidelines varied across clinics, with minimal differences across clinic size. Medical providers reported that evidence-based psychological assessment and interventions were delivered consistently by <55% of clinics. Psychosocial, compared with medical, providers were more likely to report frequent implementation of psychosocial assessment and intervention guidelines.

Conclusion

Psychological care in U.S. pediatric type 1 diabetes clinics does not consistently meet the ISPAD guidelines, and many clinics lack adequate psychosocial staff. These benchmark data are a foundational step to improve psychosocial care for pediatric patients with type 1 diabetes.

Psychosocial screening in a pediatric diabetes clinic: Adolescents' and mothers' perspectives

OBJECTIVE

Adolescents with type 1 diabetes (T1D) frequently experience psychosocial concerns, and mental health screening is becoming increasingly common in routine diabetes care. However, little is known about what adolescents or their caregivers think about the role of mental health screening and intervention within the context of comprehensive diabetes care, or how their diabetes care providers should be involved in navigating mental health concerns. This study used qualitative methods to obtain the perspectives of adolescents with T1D and their caregivers regarding these issues.

METHODS

Participants were 13 adolescents with T1D (ages 12-19 years; M = 15.1 years; 53.8% female; 61.5% Hispanic/Latinx White) and 13 mothers, recruited from an outpatient pediatric endocrinology clinic in South Florida, who participated in semi-structured interviews via video teleconference. Thematic content analysis was used to evaluate participants' responses.

RESULTS

Adolescents and their mothers reported positive experiences with the clinic's psychosocial screening procedures and appreciated meeting with the psychology team during visits. They wanted the clinic to offer more opportunities for peer support. Mothers highlighted barriers to seeking mental health care outside of the clinic and the importance of mental health professionals understanding diabetes. Mothers also wanted the clinic to offer more on-site therapeutic services.

DISCUSSION

Study participants valued psychosocial screening and supported addressing mental health as a routine part of diabetes comprehensive care.

Role of Psychologists in Pediatric Endocrinology

The care of youth managed within pediatric endocrine clinics is complex and requires a multi- or interdisciplinary approach. Psychosocial aspects of chronic health conditions are well-documented. Clinical practice guidelines outline the importance of routine psychosocial screening and support for youth with diabetes and obesity. This article outlines the diverse role of psychologists in pediatric endocrinology, including screening, in-clinic intervention, outpatient psychological services, and inpatient consultation. Although research exists documenting the effectiveness of behavioral interventions to improve adherence and health-related quality of life, cost analysis research is emerging.