Where are kids being treated for concussions?


A new report looks at where parents are seeking care for their children following a concussion.

Whereas most data on concussions has focused on those patients treated in emergency departments (EDs) or through high school athletic groups, a new study reveals that a third of all concussion cases occur in younger children, and that most children suffering from concussions are treated in the primary care setting.

Christina L Master, MD, CAQSM, lead author of the study, and associate program director of the Primary Care Sports Medicine Fellowship and attending physician, the Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia (CHOP), says the findings highlight the need for more resources for diagnosis and management of concussions in the primary care setting, as well as more scrutiny on possibly skewed concussion prevalence statistics.

Master’s study analyzed the number of children with concussions who were treated by primary care physicians (PCPs) as opposed to in EDs and found that 82% were treated in primary care compared with just 12% in ED settings. Treatment in the ED was highest among younger children and those insured by Medicaid.

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The research team collected data on children aged 0 to 17 years who were examined for concussions at CHOP using data from electronic health records. More than 8000 cases were reviewed, and the team found that 52% of children aged 0 to 4 years were initially seen in the ED, and about 75% of those aged 5 to 17 years were first seen in the primary care setting.

Insurance status influenced where initial treatment occurred, with 37% of Medicaid patients using ED care compared with 7% of private patients and 24% of self-pay patients.

Race and ethnicity also played a role in where children were seen for concussions, with 42.4% of non-Hispanic black patients seeking care in the ED compared with 4.9% of non-Hispanic white patients. These variations could lead to overestimating or underestimating concussion prevalence among different racial groups, and statistics should be considered with caution, according to the report.

The study also revealed important information about the prevalence of concussions in children, because data previously focused on high school athletes and individuals treated within EDs. The researchers found that about one-third of all concussion patients were aged younger than 12 years, revealing a “critical need” for more research about age-appropriate diagnostic and treatment strategies across the pediatric spectrum.

The number of children treated for concussions overall increased during the 4-year study period, according to the report. Initial visits for concussions within primary care increased 13% from 2010 to 2014, whereas initial visits in the ED increased by 16% over the same period.

The researchers point out that concussion prevalence based on figures from ED visits alone underscores the prevalence of these injuries, but also highlights the importance of primary care in concussion management.

Pediatricians should be increasing awareness of concussions, particularly related to sports, which will likely result in a rise in the number of concussions seen in clinical practice, Master says.

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Recent evidence of the effects concussions can have on academic performance, behavioral changes, and neurocognitive deficits have led to increased awareness of concussions, particularly related to sports played by children and teenagers.

Master says the research team anticipated that a large number of families sought care for children with concussions in the primary care setting as opposed to EDs, but they were surprised at how high the number actually was—82%. “I think it exemplifies how well the pediatric medical home can function in a large pediatric healthcare network—providing the right care to the right patient at the right time in the right place—with all the emergency and specialty support available at the pediatrician's fingertips, if needed,” she says.

The study also highlights the importance of the primary care setting in concussion treatment and management, which may help PCPs advocate for increased training and resources for concussion clinical decision support tools within their healthcare systems, according to the report.

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Higher utilization of primary care offices over EDs may be attributed in part to payment models and the ease with which children were able to get appointments with their PCPs, the report shows, but ED utilization among younger children also correlated with overall higher rates of ED use among these patients. Where concussions are concerned, this higher prevalence might be related to the fact that infants and toddlers are often unable to describe the events leading to and the symptoms of their injury, making accurate concussion diagnosis in this age group more difficult.

Pediatricians recently have expressed concern that they lack up-to-date concussion training or resources for accurate diagnosis and ongoing case management. The study notes that understanding where children with concussions seek care may provide valuable information to help health systems determine where more resources and training should be deployed. The Institute of Medicine also recently revealed that there is a lack of data on concussions treated outside of EDs and organized athletics.

The researchers suggest that specialized training for concussion diagnosis and treatment may be warranted for younger populations, with different symptom descriptions based on pediatric age groups.

The CHOP has made resources available to families and pediatricians with the latest information about concussion diagnosis and care, including instructional videos. “With tools and support, pediatricians can manage most concussions (80% to 90%) [that resolve] with some supportive care over the course of a few weeks and return [patients] to full life and recreational activities,” Master says.

She adds that she hopes the report will lead to better understanding of concussion prevalence and the portals of care used, as well as increase resources for PCPs.

“We hope that pediatricians realize that, as the pediatric medical home for children, they are the best place for patients to start their care, and that pediatricians feel empowered to care for most pediatric concussions and provide the most current information in our understanding of concussion to patients,” Master says, adding that CHOP also offers an annual Continuing Medical Education course for physicians and allied health professionals.

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