Most Children Receive Concussion Care in Primary Care, Not ED

Troy Brown, RN

June 02, 2016

Most children with concussions go first to their primary care provider, rather than an emergency department (ED), for treatment, a new study shows. The findings suggest that current incidence estimates for concussions are too low, and that primary care clinicians need to be prepared to diagnose and treat these injuries, the researchers say.

"[U]sing a novel method to leverage rich data captured in a unified EHR [electronic health record] system on a diverse demographic and socioeconomic population, this study suggests that incidence estimates of pediatric concussion that rely solely on ED records substantially underestimate the true incidence of this injury," the researchers write.

Kristy B. Arbogast, PhD, from the Center for Injury Research and Prevention, The Children's Hospital of Philadelphia (CHOP), and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, and colleagues present their findings in an article published online May 31 in JAMA Pediatrics.

The investigators analyzed EHR data from 8083 patients aged 0 to 17 years who had an initial visit for concussion at CHOP or one of its care centers from July 1, 2010, to June 30, 2014. EHRs are used for all aspects of clinical care throughout the CHOP network.

Overall, 81.9% (95% confidence interval [CI], 81.1%- 8 2.8%; n = 6624) of the children had their initial concussion visit with a primary care clinician, 5.2% (95% CI, 4.7% - 5.7%; n = 418) were first seen within specialty care, 11.7% (95% CI, 11.0% - 12.4%; n = 947) were first seen in the ED, and 1.2% (95% CI, 0.9% - 1.4%; n = 94) were admitted directly to the hospital.

"[U]nlike many other types of traumatic injuries, children with concussion potentially enter the health care system through a variety of portals, including primary care or specialty care such as sports medicine or neurology, in addition to the [ED] and urgent care," the authors explain.

Of CHOP primary care patients, the proportion who obtained concussion care at their primary care office rose 13% between July to September 2010 and April to June 2014 (from 72.4% [184/254] to 81.7% [503/616]), whereas the proportion of those who sought care at the ED fell 16% during the same period (15.4% [39/254] to 13.0% [80/616]).

"Our results highlight the critical importance of primary care clinicians in concussion care," the authors write. "This may be driven in part by insurance reasons or the fact that patients can often be scheduled for office appointments in the primary care setting sooner and at lesser expense than in specialty care or the ED. Regardless of the reason, these data provide critical guidance to health care networks, alerting them that the primary care setting is increasingly being used for concussion care and those clinicians may be in need of augmented training or increased resources."

Significant Variations by Age

The patients' median age was 13 years (interquartile range, 10 - 15 years). Children older than 4 years accounted for most of the cases: 4.6% of the children (n = 368) were aged 0 to 4 years, 30.8% (n = 2492) were aged 5 to 11 years, 34.9% (n = 2820) were aged 12 to 14 years, and 29.7% (n = 2403) were aged 15 to 17 years.

However, a significantly higher proportion of children aged 4 years and younger were seen in the ED, at 51.9% (95% CI, 46.8% - 57.0%; 191/368) compared with 14.9% (371/2492) of children aged 5 to 11 years (95% CI, 13.5%-16.3%), 7.9% (222/2820) of children aged 12 to 14 years (95% CI, 6.9% - 8.9%), and 6.8% (163/2403) of children aged 15 to 17 years (95% CI, 5.8% - 7.8%).

"Conversely, more than three-quarters of those aged 5 to 17 years...initially sought care at CHOP via primary care," the authors note.

Race/Ethnicity, Payor Differences

The researchers also saw differences in presentation setting when they analyzed the data by race/ethnicity and insurance type. Specifically, more non-Hispanic black patients (42.4%; 95% CI, 39.8% - 45.0%; 586/1383) sought care in the ED compared with 4.9% (95% CI, 4.3% - 5.4%;280/5729) of non-Hispanic white children.

Most of the children had private insurance (n = 6652; 82.3%). Only 6.5% (95% CI, 5.9% - 7.1%; 435/6652) of those with private insurance sought care in the ED compared with 37.1% (95% CI, 34.4% - 39.7%; 478/1290) of children with Medicaid and 24.1% (95% CI, 17.1% - 31.2%; 34/141) who were self-pay.

"Important variations in the point of health care entry by age, race/ethnicity, and payor also suggest the accuracy of incidence estimates based on a single point of health care entry may vary for these different subgroups. These differences may lead to targeted interventions to improve recognition and management of concussion in these populations," the researchers explain. "In addition, the increased use of EHRs may provide an opportunity to leverage health records for research into the natural history of concussion that may lead to improvements in the prevention, diagnosis, and management of this common childhood injury," the authors conclude.

The authors have disclosed no relevant financial relationships.

JAMA Pediatr. Published online May 31, 2016. Full text

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