Follow-Up Care Adherence After Hospital Discharge in Children With Traumatic Brain Injury

Follow-up visits after pediatric concussion and the factors associated with early follow-up: a population-based study in British Columbia

OBJECTIVES

To explore the rates and timing of a first follow-up visit for children and adolescents with a concussive injury and to identify factors associated with follow-up timing.

METHODS

A descriptive, correlational design drawing on linked, population-based administrative data of concussed children and adolescents (ages 5-18 years) from the province of British Columbia (BC), Canada. Data were accessed through Population Data BC. Descriptive statistics and binary logistic regression were used to analyze the data.

RESULTS

From January 1, 2016 to December 31, 2017, we retrieved 22,601 cases of concussion, of which 19% had an early follow-up visit (N = 4,294), 4.9% had later follow-up (N = 1,107), and 76.1% had no follow-up (N = 17,200). The factors of older age, living in a rural area, higher socioeconomic status, and seeing a specialist physician at an initial concussion diagnosis were more likely to have an early follow-up visit.

CONCLUSION

Early follow-up is important for recovery, but most children and adolescents with a concussion do not receive follow-up in BC.

Adherence with post-hospitalization follow-up after pediatric critical illness due to respiratory failure

BACKGROUND

Adherence with follow-up appointments after a pediatric intensive care unit (PICU) admission is likely a key component in managing post-PICU sequalae. However, prior work on PICU follow-up adherence is limited. The objective of this study is to identify hospitalization characteristics, discharge child health metrics, and follow-up characteristics associated with full adherence with recommended follow-up at a quaternary care center after a PICU admission due to respiratory failure.

METHODS

We conducted a retrospective cohort study of patients ≤ 18 years with respiratory failure admitted between 1/2013-12/2014 to a quaternary care PICU. Post-hospitalization full adherence with recommended follow-up in the two years post discharge (1/2013-3/2017) at the quaternary care center was quantified and compared by demographics, baseline child health metrics, hospitalization characteristics, discharge child health metrics, and follow-up characteristics in bivariate and multivariate analyses. Patients were dichotomized into being non-adherent with follow-up (patients who attended less than 100% of recommended appointments at the quaternary care center) and fully adherent (patients who attended 100% of recommended appointments at the quaternary care center).

RESULTS

Of 155 patients alive at hospital discharge, 140 (90.3%) were recommended to follow-up at the quaternary care center. Of the 140 patients with recommended follow-up at the quaternary care center, 32.1% were non-adherent with follow-up and 67.9% were fully adherent. In a multivariable logistic regression model, each additional recommended unique follow-up appointment was associated with lower odds of being fully adherent with follow-up (OR 0.74, 95% CI 0.60-0.91, p = 0.005), and each 10% increase in the proportion of appointments scheduled before discharge was associated with higher odds of being fully adherent with follow-up (OR 1.02, 95% CI 1.01-1.03, p = 0.004).

CONCLUSIONS

After admission for acute respiratory failure, only two-thirds of children were fully adherent with recommended follow-up at a quaternary care center. Our findings suggest that limiting the recommended follow-up to only key essential healthcare providers and working to schedule as many appointments as possible before discharge could improve follow-up adherence. However, a better understanding of the factors that lead to non-adherence with follow-up appointments is needed to inform broader system-level approaches could help improve PICU follow-up adherence.

Analysis of a novel virtual pediatric concussion clinic in a rural setting

PURPOSE

Children and adolescents who sustain concussion in rural communities are lost to follow-up after initial evaluation more often than their urban counterparts. Thus, this study aims to determine the feasibility and accessibility of a novel virtual pediatric concussion clinic at a rural academic hospital.

METHODS

Data regarding patients referred to a virtual concussion clinic at a rural Pediatric Level 2 Trauma Center over a 16-month period was prospectively collected. Patients experiencing concussive symptoms were referred to the pediatric neurosurgery clinical registered nurse and received a phone call following an injury. Referrals to therapy were made based on symptoms reported.

RESULTS

Data from 44 patients was collected: 9 did not follow-up in concussion clinic despite leaving a voicemail. Forty-three were referred from the emergency department. The median time from referral placed to completing a virtual follow-up was 4.5 days. Among the referrals, 3 (8.6%) were to pediatric neurology, 10 (28.6%) to occupational therapy (OT), 6 (17.1%) to physical therapy (PT), 4 (11.4%) to speech-language pathology (SLP), and 25 (71.4%) did not receive referrals as their symptoms had abated. Patients followed with pediatric neurology post-injury for an average of 75.9 days, OT for an average of 52.7 days, and PT for an average of 2.3 days.

CONCLUSION

This is a feasible model to follow patients and place referrals for additional therapeutic services in a rural community. With 79.5% of patients completing a follow-up, the clinic demonstrates easy accessibility and reliable adherence.

Long-Term Outcomes of Pediatric Traumatic Brain Injury Following Inpatient Rehabilitation

OBJECTIVE

Assess residual disability in youth with traumatic brain injury (TBI) treated in a pediatric inpatient rehabilitation unit and examine associations of disability with inpatient status and measures of concurrent functioning.

SETTING

Large, urban, quaternary care children's hospital in the Midwestern United States.

PARTICIPANTS

Forty-five youth aged 6 to 18 years treated in an inpatient rehabilitation unit for mild-complicated to severe TBI at a minimum of 12 months postdischarge (mean = 3.5 years).

DESIGN

Retrospective chart review of clinical data collected from standard clinical care at admission and discharge combined with follow-up data examining current functioning at the time of study enrollment.

MAIN OUTCOME MEASURES

Glasgow Outcome Scale-Extended, Pediatric Revision (GOS-E Peds), Neurology Quality of Life Measurement System Short Form (NeuroQOL) Social Interaction with Peers and Cognitive Short Forms, Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Scale, Strengths and Difficulties Questionnaire, and the Behavior Rating Inventory of Executive Function, 2nd Edition (BRIEF-2).

RESULTS

Based on parent report at follow-up, 62% of the children had residual TBI-related disabilities on the GOS-E Peds, while 38% reported "good recovery." Children with residual disability also reported more long-term problems in overall health, social relationships, emotional regulation, behaviors, and executive functioning than those with no residual disability. Measures of functional independence and cognitive recovery at discharge were associated with these impairments.

CONCLUSIONS

More than half of the children with TBI in this study had residual disability more than 1 year after inpatient rehabilitation. Findings highlight the associations between measures of functional independence and cognitive recovery during inpatient rehabilitation with later outcomes and underscore the need for continued services to support the needs of children with TBI following their inpatient rehabilitation stay.

Using Billing Codes to Create a Pediatric Functional Status e-Score for Children Receiving Inpatient Rehabilitation

OBJECTIVE

Provide proof-of-concept for development of a Pediatric Functional Status eScore (PFSeS). Demonstrate that expert clinicians rank billing codes as relevant to patient functional status and identify the domains that codes inform in a way that reliably matches analytical modeling.

DESIGN

Retrospective chart review, modified Delphi, and nominal group techniques.

SETTING

Large, urban, quaternary care children's hospital in the Midwestern United States.

PARTICIPANTS

Data from 1955 unique patients and 2029 hospital admissions (2000-2020); 12 expert consultants representing the continuum of rehabilitation care reviewed 2893 codes (procedural, diagnostic, pharmaceutical, durable medical equipment).

MAIN OUTCOME MEASURES

Consensus voting to determine whether codes were associated with functional status at discharge and, if so, what domains they informed (self-care, mobility, cognition/ communication).

RESULTS

The top 250 and 500 codes identified by statistical modeling were mostly composed of codes selected by the consultant panel (78%-80% of the top 250 and 71%-78% of the top 500). The results provide evidence that clinical experts' selection of functionally meaningful codes corresponds with codes selected by statistical modeling as most strongly associated with WeeFIM domain scores. The top 5 codes most strongly related to functional independence ratings from a domain-specific assessment indicate clinically sensible relationships, further supporting the use of billing data in modeling to create a PFSeS.

CONCLUSIONS

Development of a PFSeS that is predicated on billing data would improve researchers' ability to assess the functional status of children who receive inpatient rehabilitation care for a neurologic injury or illness. An expert clinician panel, representing the spectrum of medical and rehabilitative care, indicated that proposed statistical modeling identifies relevant codes mapped to 3 important domains: self-care, mobility, and cognition/communication.

Predicting Outcomes 2 Months and 1 Year After Inpatient Rehabilitation for Youth With TBI Using Duration of Impaired Consciousness and Serial Cognitive Assessment

OBJECTIVE

To examine predictive utility of the Glasgow Coma Scale (GCS), time to follow commands (TFC), length of posttraumatic amnesia (PTA), duration of impaired consciousness (TFC+PTA), and the Cognitive and Linguistic Scale (CALS) scores in predicting outcomes on the Glasgow Outcome Scale-Extended, Pediatric Revision (GOS-E Peds) for children with traumatic brain injury (TBI) at 2 months and 1 year after discharge from rehabilitation.

SETTING

A large, urban pediatric medical center and inpatient rehabilitation program.

PARTICIPANTS

Sixty youth with moderate-to-severe TBI (mean age at injury = 13.7 years; range = 5-20).

DESIGN

A retrospective chart review.

MAIN MEASURES

Lowest postresuscitation GCS, TFC, PTA, TFC+PTA, inpatient rehabilitation admission and discharge CALS scores, GOS-E Peds at 2-month and 1-year follow-ups.

RESULTS

CALS scores were significantly correlated with the GOS-E Peds at both time points (weak-to-moderate correlation for admission scores and moderate correlation for discharge scores). TFC and TFC+PTA were correlated with GOS-E Peds scores at a 2-month follow-up and TFC remained a predictor at a 1-year follow-up. The GCS and PTA were not correlated with the GOS-E Peds. In the stepwise linear regression model, only the CALS at discharge was a significant predictor of the GOS-E Peds at the 2-month and 1-year follow-ups.

CONCLUSIONS

In our correlational analysis, better performance on the CALS was associated with less long-term disability, and longer TFC was associated with more long-term disability, as measured by the GOS-E Peds. In this sample, the CALS at discharge was the only retained significant predictor of GOS-E Peds scores at 2-month and 1-year follow-ups, accounting for roughly 25% of the variance in GOS-E scores. As previous research suggests, variables related to rate of recovery may be better predictors of outcome than variables related to severity of injury at a single time point (eg, GCS). Future multisite studies are needed to increase sample size and standardize data collection methods for clinical and research purposes.

Follow-up visits after a concussion in the pediatric population: An integrative review

BACKGROUND

Concussions are a significant health issue for children and youth. After a concussion diagnosis, follow-up visits with a health care provider are important for reassessment, continued management, and further education.

OBJECTIVE

This review aimed to synthesize and analyse the current state of the literature on follow-up visits of children with a concussive injury and examine the factors associated with follow-up visits.

METHODS

An integrative review was conducted based on Whittemore and Knafl's framework. Databases searched included PubMed, MEDLINE, CINAHL, PsycINFO, and Google Scholar.

RESULTS

Twenty-four articles were reviewed. We identified follow-up visit rates, timing to a first follow-up visit, and factors associated with follow-up visits as common themes. Follow-up visit rates ranged widely, from 13.2 to 99.5%, but time to the first follow-up visit was only reported in eight studies. Three types of factors were associated with attending a follow-up visit: injury-related factors, individual factors, and health service factors.

CONCLUSION

Concussed children and youth have varying rates of follow-up care after an initial concussion diagnosis, with little known about the timing of this visit. Diverse factors are associated with the first follow-up visit. Further research on follow-up visits after a concussion in this population is warranted.

Factors that Influence Follow-Up Care for Families of Children with Acquired Brain Injury: A Scoping Review

PURPOSE

To describe factors that contribute to medical/rehabilitation service access following pediatric acquired brain injury (ABI) and identify gaps in the literature to guide future research.

MATERIALS & METHODS

The PRISMA framework for scoping reviews guided this process. Peer-reviewed journal databases were searched for articles published between 1/2008 and 12/2020, identifying 400 unique articles. For full inclusion, articles had to examine a variable related to the receipt or initiation of medical/rehabilitative services for children with ABI. Review articles and non-English articles were excluded.

RESULTS

Nine studies met full inclusion criteria. Included studies identified factors focused on four primary areas: understanding brain injury education/recommendations and ease of implementing recommendations, ease of scheduling and attending appointments, age/injury factors, and sociocultural factors. Well-scheduled appointments and simple strategies facilitated families' access to care and implementation of recommendations. An overwhelming number of recommendations, socioeconomic variables, and transportation challenges served as barriers for families and schools.

CONCLUSIONS

This scoping review offers several directions on which researchers can build to improve access to care and recommendation-implementation for families who have a child with an ABI. Enhanced understanding of these factors may lead to better service access, reduction of unmet needs, and enhanced long-term outcomes for children with ABI.

Outpatient follow-up after pediatric surgery reduces emergency department visits and readmission rates

PURPOSE

The factors affecting outpatient follow-up (OFU) after pediatric surgery have not been well studied. We evaluate factors impacting OFU and the effect of OFU in pediatric surgical patients.

METHODS

A retrospective review of all pediatric patients operated on by the Division of Pediatric Surgery from February 1st to September 30th, 2017, and subsequently discharged was performed.

RESULTS

1242 patients were identified. Overall OFU was 69.6%. Language and distance between patient residence and the hospital had no impact on OFU. Inpatient surgical patients followed-up at a higher rate than ambulatory surgical patients (72.7% vs 64.8%, p < 0.01). Out-of-system transfers had the lowest OFU rate at 52.8% (p < 0.001). Insurance type and patient age had a significant impact on OFU rates. Thirty-day ED visit and readmission rates were significantly lower in those patients with OFU than in those without (8.8% vs 12.7%, p = 0.04 and 3.7% to 11.0%, p < 0.001, respectively). OFU was more beneficial in patients with inpatient procedures or longer hospitalization lengths of stay than in the cohort of ambulatory patients.

CONCLUSIONS

Socioeconomic status, hospital presentation, and procedural complexity influenced rates of OFU. OFU was associated with significant reductions in 30-day ED visits and readmissions, and this benefit was more pronounced for complex procedures or patients.

TYPE OF STUDY

Retrospective review.

LEVEL OF EVIDENCE

Level III.

Attending Follow-up Appointments After Pediatric Traumatic Brain Injury: Caregiver-Perceived Barriers and Facilitators

OBJECTIVE

To examine barriers and facilitators for follow-up care of children with traumatic brain injury (TBI).

SETTING

Urban children's hospital.

PARTICIPANTS

Caregivers of children (aged 2-18 years) discharged from an inpatient unit with a TBI diagnosis in 2014-2015.

DESIGN

Survey of caregivers.

MAIN MEASURES

Caregiver-reported barriers and facilitators to follow-up appointment attendance.

RESULTS

The sample included 159 caregivers who completed the survey. The top 3 barriers were "no need" (38.5%), "schedule conflicts" (14.1%), and "lack of resources" (10.3%). The top 5 identified facilitators were "good hospital experience" (68.6%), "need" (37.8%), "sufficient resources" (35.8%), "well-coordinated appointments" (31.1%), and "provision of counseling and support" (27.6%). Caregivers with higher income were more likely to report "no need" as a barrier; females were less likely to do so. Nonwhite caregivers and those without private insurance were more likely to report "lack of resources" as a barrier. Females were more likely to report "good hospital experience" and "provision of counseling and support" as a facilitator. Nonwhite caregivers were more likely to report "need" but less likely to report "sufficient resources" as facilitators.

CONCLUSIONS

Care coordination, assistance with resources, and improvements in communication and the hospital experience are ways that adherence might be enhanced.

The impact of driving time on pediatric TBI follow-up visit attendance

Objective: Examine the effect of driving time on follow-up visit attendance for children hospitalized with a traumatic brain injury (TBI). We hypothesized that families who lived further from the hospital would show poorer follow-up attendance.Participants: 368 children admitted to the hospital with TBI.Design & Outcome Measures: Using a retrospective chart review, we calculated driving time from patients' homes. The primary outcome was attendance at the first appointment post-discharge. We used logistic regression to examine the effect of driving time on attendance, including an analysis of the effects of injury and sociodemographic covariates on the model.Results: Majority of children attended their first appointment. Patients living 30-60 min from the hospital were most likely to attend, and those living 15 min away were least likely to attend. After adjusting for patient characteristics, families with driving time of 30-60 min had significantly higher odds of returning for follow-up than those with driving time <15 min, though the significance of this relationship disappeared after specific socioeconomic (SES) factors were included.Conclusions: Distance plays a significant role on follow-up attendance for pediatric patients with TBI. However, neighborhood SES may be an additional factor that influences the significance of the distance effect.Abbreviations: TBI: Traumatic brain injury; SES: socioeconomic status; ISS: Injury severity scale; AIS: Abbreviated injury scale.

The Speech-Language Pathologists' Role in Mild Traumatic Brain Injury for Early Childhood-, Preschool-, and Elementary School-Age Children: Viewpoints on Guidelines From the Centers for Disease Control and Prevention

Purpose Traumatic brain injury (TBI) impacts millions of children each year, with those between birth and 4 years of age being 1 of the highest incidence groups. To address gaps in service provision specifically for children with mild TBI (mTBI), the Centers for Disease Control and Prevention (CDC) recently released guidelines for providers. Method The goal of this commentary is to deliver viewpoints on the application of the CDC guidelines directly to speech-language pathology clinical practice, with special attention paid to assessment, symptom monitoring, and intervention using a family-centered approach to care for infants, toddlers, preschoolers, and early elementary students with mTBI. Results In all pediatric practice settings, speech-language pathologists (SLPs) are a critical component of the care team for children who experience mTBI and should participate in symptom monitoring, assessment, intervention, education, and advocacy for this population. Conclusions SLPs can use the CDC guidelines to advocate for their role in the care of young children with mTBI. In addition, SLPs can use the guidelines to create a framework for clinical care provision when working with young children with mTBI. Much work is needed to advance evidence-based practices for this population, and dissemination of current clinical practices could help to close this gap.

Functional and patient-reported outcome versus in-hospital costs after traumatic acute subdural hematoma (t-ASDH): a neurosurgical paradox?

BACKGROUND

The decision whether to operate or not in patients with a traumatic acute subdural hematoma (t-ASDH) can, in many cases, be a neurosurgical dilemma. There is a general conception that operating on severe cases leads to the survival of severely disabled patients and is associated with relatively high medical costs. There is however little information on the quality of life of patients after operation for t-ASDH, let alone on the cost-effectiveness.

METHODS

This study retrospectively investigated patient outcome and in-hospital costs for 108 consecutive patients with a t-ASDH. Patient outcome was assessed using the Glasgow Outcome Score (GOS) and the Traumatic Brain Injury (TBI)-specific QOLIBRI questionnaire. The in-hospital costs were calculated using the Dutch guidelines for costs calculation.

RESULTS

Out of 108 patients, 40 were classified as having sustained a mild (Glasgow Coma Scale (GCS) 13-15), 19 a moderate (GCS 9-12), and 49 a severe (GCS 3-8) TBI. As expected, mortality rates increased with higher TBI severity (23%, 47%, and 61% respectively), whereas the chance for favorable outcome (GOS 4-5) decreased (72%, 47%, and 29%). Interestingly, the mean QOLIBRI scores for survivors were quite similar between the TBI severity groups (61, 61, and 64). Healthcare consumption and in-hospital costs increased with TBI severity. In-hospital costs were relatively high (€24,980), especially after emergency surgery (€28,670) and when additional ICP monitoring was used (€36,580).

CONCLUSIONS

Although this study confirms that outcome is often "unfavorable" after t-ASDH, it also shows that "favorable" outcome can be achieved, even in the most severely injured patients. In-hospital treatment costs were substantial and mainly related to TBI severity, with admission and surgery as main cost drivers. These results serve as a basis for necessary future research focusing on the value-based cost-effectiveness of surgical treatment of patients with a t-ASDH.

Putting the person in person-centered care: Stakeholder experiences in pediatric traumatic brain injury

PURPOSE

This pilot study sought to describe the perspectives and experiences of survivors of pediatric traumatic brain injury (pTBI), their caregivers, and the medical professionals who serve them.

METHODS

Thirteen people participated in semi-structured interviews: five survivors of pTBI, their primary caregivers, and three medical professionals who work with persons who have sustained pTBI. The study involved a prospective, qualitative, participatory action research model with convenience sampling. All interviews were transcribed and thematic analysis identified central concepts within and between groups. Additionally, the Consolidated Criteria for Reporting Qualitative Research (COREG) were applied.

RESULTS

This study found that survivors of pTBI and their caregivers commonly noted later developing issues, social challenges, and difficulty in post-rehabilitation transitions. In addition, both caregivers and medical professionals reported the need for improved follow-up with survivors, evidence-based research, and medical and therapy providers with specific training on pTBI.

CONCLUSIONS

The perspectives provided by key stakeholders in this pilot study identify common themes that should be central to driving innovation in rehabilitation research and clinical care.