Concussion Diagnoses Doubled But No Greater Admissions

Daniel M. Keller, PhD

May 07, 2012

May 7, 2012 (Boston, Massachusetts) — In the past decade, the number of children diagnosed with concussion has doubled, but the number of patients with concussion who are admitted to the hospital has remained constant. Although brain imaging is common, neurocognitive testing of these patients is rarely done in the emergency department (ED), Jeffrey Colvin, MD, JD, assistant professor of pediatrics at Children's Mercy Hospitals and Clinics in Kansas City, Missouri, reported in a poster session here at the Pediatric Academic Societies 2012 Annual Meeting.

Dr. Jeffrey Colvin

In the United States, more than 170,000 children currently present to the ED with concussion annually (about 1 of every 160 pediatric ED patients). It has not been clear whether the increasing number of visits has resulted from increased incidence, increased awareness, or some combination of the 2.

Dr. Colvin and colleagues set out to determine the number of ED visits, the number of subsequent concussion-related admissions, and the use of imaging, medications, and neurcognitive testing on these patients.

In a cross-sectional study of free-standing children's hospitals in the Pediatric Health Information System database, the researchers examined the records of patients 18 years old or younger seen in or admitted through the ED with a primary discharge diagnosis of concussion, postconcussion syndrome, or skull fracture. They looked at 14 children's hospitals from 2001 to 2010. To evaluate current assessment and management of concussion, the researchers gathered data from 30 children's hospitals from April 2007 to September 2009.

More Than Double the Diagnoses; Admission Rate Stable

For the 10-year period of 2001 to 2010, "we found that the number of children diagnosed with concussion during that time more than doubled. It went from 2126 (95% confidence interval [CI], 2037 to 2218) to 4967 (95% CI, 4830 to 5107)," Dr. Colvin told Medscape Medical News. "At the same time, the number of children who were admitted with concussion stayed essentially the same. It changed only from 525 (95% CI, 486 to 565) to 555 (95% CI, 512 to 600)."

Although the number of admissions for concussion was fairly constant over the entire period, the number of diagnoses rose slowly from 2001 to 2007, and then increased more sharply until 2010.

"Although we can't say for certain, [it looks like] the word is getting out that concussions are important, [and] can have serious health ramifications if they're not appropriately treated and diagnosed," Dr. Colvin said. He thinks that more children are seeking care and that more parents, trainers, coaches, and teachers recognize when a child suffers a concussion and direct them to seek care.

If more concussions were occurring, "you would probably see the number of admissions also rising," which has not happened, he said. It is possible that less serious concussions are now being diagnosed, when they might not have been in the past.

Dr. Colvin said there is value in recognizing those cases because children with even subtle signs of concussion can go on to reinjury, or might perform poorly in school or have attention or memory problems. Symptoms can persists for days to months. Before the child can go back to sports, Dr. Colvin said a physician needs to do a full evaluation to make sure that all symptoms of concussion have resolved.

From 2007 to 2009, 59.9% of pediatric patients with concussion underwent computed tomography (CT) imaging of the brain, 14.8% underwent cervical spine x-ray, but only 0.04% underwent neurocognitive testing in the ED. Of the cohort, 14% was admitted to the hospital or to an observation unit and 8.6% went to the intensive care unit. Medications included nonnarcotic analgesics (26.2%), intravenous (IV) fluids (15.3%), antiemetics (14.3%), and narcotic drugs (6.7%). Readmission to the ED was only 0.5%.

Mark Halstead, MD, assistant professor in the Departments of Pediatrics and Orthopedics and director of the sports concussion clinic at Washington University Sports Medicine in St. Louis, Missouri, who had no connection with the study, said in an email that these findings are consistent with several recent studies showing a trend toward increasing numbers of patients being seen in the ED for concussion.

He said the proportion of patients undergoing CT scans for concussion is "somewhat alarming... We know it is not a structural injury, and we know that less than 1% of concussions will have any findings on a CT scan," and they are usually not related to the concussion. Even fewer require neurosurgical intervention. If almost two thirds of pediatric patients with concussion coming into the ED are getting CT scans, "we are not doing a good job screening for things that are true indications for them," he advised, "and too many kids are getting unnecessary radiation for an injury that does not show up on a CT scan."

He wondered if they are being done to rule out something worse that would require hospital admission and, when nothing is found, allowing the ED physician to feel more comfortable about discharging the patient. He also said he was "a little confused" about why patients with skull fractures were included in the study since, to him, it is "a different injury than truly just a concussion."

Dr. Halstead does not think that the very low level of neurocognitive testing in the ED is a problem. "Several recent studies have not shown it to be predictive of recovery course or useful in the management in the ED setting," or afterward, while the patient is still symptomatic, he noted.

Management and Follow-Up

Dr. Halstead said he is not aware of any medications that have been demonstrated to improve the recovery from a concussion. One problem with any study looking at whether or not an intervention helps is that it is not possible to predict the typical time course of recovery for any patient. "It is unclear if any medication would shorten or lengthen that time course," he said.

Medications are often used to reduce symptoms, but it is unclear if they hasten recovery. "I'm not sure why as many patients in the ED with a concussion diagnosis are getting IV fluids," he said.

Dr. Halstead said he does not like to rate concussions by degree of severity. "Either you were concussed or not," he emphasized. "We don't know that a mild concussion has any different long-term consequences than a severe concussion." All should be followed up and, if seen initially in the ED, a primary care provider or a sports medicine specialist should clear the patient prior to a return to athletic play. "I don't believe the ED is the place to receive clearance to return to sports," he advised.

Although it is impossible to prove from the study findings, both Dr. Colvin and Dr. Halstead think that the doubling in concussion diagnoses is a result of efforts to raise awareness and not a true increase in the incidence of concussions. The National Football League, the National Hockey League, professional medical groups, and the media have made efforts to educate athletes and to raise public awareness.

Dr. Colvin and Dr. Halstead have disclosed no relevant financial relationships.

Pediatric Academic Societies (PAS) 2012 Annual Meeting: Abstract 1501.74. Presented Apri 28, 2012.

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