Characteristics and Costs of Pediatric Emergency Department Visits for Sports- and Recreation-Related Concussions, 2006-2014

Factors associated with follow-up care after pediatric concussion: A longitudinal population-based study in Alberta, Canada

BACKGROUND

Concussion is a common injury in children and adolescents. Current best practice guidelines indicate that recovery should be supervised through recurrent follow-up visits. A more detailed understanding of the system-level and individual factors that are associated with follow-up care is a critical step towards increasing evidence-based practice. The objective of this study was to identify predisposing, enabling, and need-based factors associated with follow-up care after pediatric concussion.

MATERIALS AND METHODS

A retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age with a diagnosis of concussion, other specified injuries of the head, unspecified injury of head, or post-concussion syndrome (PCS) between April 1, 2004 and March 31, 2018 in Alberta, Canada. The association between predisposing, enabling, and need-based factors and the receipt of follow-up care within a defined episode of care (EOC) was analyzed using logistic regression models for the entire cohort and for EOC that began with a concussion diagnosis. Predisposing factors included age and sex. Enabling factors included the community type of patient residence, area-based socioeconomic status (SES), and visit year. Need-based factors included where the EOC began (outpatient vs. emergency settings) and history of previous concussion-related EOC.

RESULTS

194,081 EOCs occurred during the study period but only 13% involved follow-up care (n = 25,461). Males and adolescents were more likely to receive follow-up care. Follow-up was less likely among patients who lived in remote communities or in areas of lower SES, while EOCs beginning in 2011 or later were more likely to involve follow-up care. Patients whose EOC began in outpatient settings, had more than one EOC, or a diagnosis of concussion were more likely to receive follow-up care.

CONCLUSION

Follow-up care for pediatric concussion has increased over time and is associated with patient age and sex, history of concussion-related EOC, where a patient lives (community type and area-based SES), and when and where the index visit occurs. A better understanding of which children are more likely to receive follow-up care, as well as how and when they do, is an important step in aligning practice with follow-up guidelines.

Influence of insurance type on rate and type of initial concussion-related medical visits among youth

Background

A growing number of studies report increased concussion-related health care utilization in recent years, but factors impacting care-seeking behaviors among youth following a concussion are not well described. This study aimed to evaluate the influence of insurance type on the rate and type of initial concussion visits and the time from injury to the initial visit in youth.

Methods

We extracted and analyzed initial concussion-related medical visits for youth ages 10 to 17 from electronic health records. Patients must have visited Nationwide Children’s Hospital’s (NCH) concussion clinic at least once between 7/1/2012 and 12/31/2017. We evaluated the trends and patterns of initial concussion visits across the study period using regression analyses.

Results

Of 4955 unique concussion visits included, 60.1% were males, 80.5% were white, and 69.5% were paid by private insurance. Patients’ average age was 13.9 years (SD = 3.7). The rate of the initial concussion visits per 10,000 NCH visits was consistently higher in privately insured than publicly insured youth throughout the study period (P < .0001). Privately insured youth had greater odds of initial concussion visits to sports medicine clinics (AOR = 1.45, 95% CI = 1.20, 1.76) but lower odds of initial concussion visits to the ED/urgent care (AOR = 0.74, 95% CI = 0.60, 0.90) than publicly insured youth. Days from injury to initial concussion visit significantly decreased among both insurance types throughout the study (P < .0001), with a greater decrease observed in publicly insured than privately insured youth (P = .011).

Conclusions

Results on the differences in the rate, type, and time of initial concussion-related visits may help inform more efficient care of concussion among youth with different types of insurance.

Perceptions of implementation of Massachusetts sports concussion regulations: results of a survey of athletic directors

BACKGROUND

In 2011 the Massachusetts Department of Public Health issued regulations pursuant to 2010 Massachusetts youth sports concussion legislation that provided policies and procedures for persons engaged in the prevention, training, management, and return-to-activity for students who sustain head injury during interscholastic athletics, including Athletic Directors (ADs).

METHODS

A survey instrument was developed with participation from injury prevention experts at the Boston University School of Medicine, the Massachusetts Department of Public Health, and ADs. An electronic survey was sent to all AD members of the Massachusetts Interscholastic Athletic Association to assess their perceptions of implementation of the sports concussion law.

RESULTS

Response rate was 75% (260/346). The mean rating on a 0-10 scale (10 being "very important") on importance of the law for student safety was 9.24, and the mean rating of the law's impact on workload was 5.54. Perceived impact on workload varied as a function of whether or not the school also employed an athletic trainer (t = 2.24, p = 0.03). Most respondents (88%) reported that their school had a concussion management team, and 74% reported that they were informed "always" (31%) or "often" (43%) when a student-athlete experienced a head injury in a venue other than extracurricular sports. Most respondents (95%) endorsed that "all" or "most" school nurses were "very knowledgeable" about the law and regulations. Approximately half of all respondents endorsed that "all" or "most" teachers and guidance counselors were "very knowledgeable" about the law and regulations; 76% endorsed that "all" or "most" of students' physicians were "very knowledgeable" about the law and regulations; 59% endorsed that "all" or "most" parents were "very knowledgeable" about the law and regulations. Sixty-six percent endorsed that student-athletes with concussion "often" (10%) or "sometimes" (56%) misrepresent their symptoms to accelerate return-to-play; and, 70% perceived that student-athletes with concussion "often" (15%) or "sometimes" (55%) misrepresent their symptoms to avoid academics.

CONCLUSIONS

ADs perceive the sports concussion legislation as very important to student safety and positively assess implementation of the law and associated regulations. More effort is needed to increase understanding of the law among stakeholders including teachers, parents, and physicians.

Evaluation of Implementation of Massachusetts Sports Concussion Regulations: Results of Focus Groups with Athletic Directors

In 2018, the Massachusetts Department of Public Health (MDPH) conducted focus groups with athletic directors (ADs) from Massachusetts middle and high schools to assess the implementation of legislated regulations relative to the management of concussion (mild traumatic brain injuries; mTBI) among students engaged in extracurricular sports. Two tape-recorded focus groups were conducted with a facilitator. Lists of themes were synthesized by investigators. Overall, participating ADs expressed that the law and accompanying regulations were necessary and important for protecting student athletes, despite some burdensome aspects of implementation. Emerging themes included support for the law, some implementation problems, impact on workload, and recommendations for improving mandated procedures. ADs assume an important role in the management of middle and high school students' mTBI when given the authority to do so through legislation and regulation. Nonetheless, challenges to the daily application of legislated protocols exist and should continue to be evaluated.