Abstract
OBJECTIVE: To determine the self-reported practices and attitudes surrounding concussion diagnosis and management in a single, large pediatric care network.
METHODS: A cross-sectional survey was distributed to pediatric primary care and emergency medicine providers in a single, large pediatric care network. For all survey participants, practices and attitudes about concussion diagnosis and treatment were queried.
RESULTS: There were 145 responses from 276 eligible providers, resulting in a 53% response rate, of which 91% (95% confidence interval [CI]: 86%–95%) had cared for at least 1 concussion patient in the previous 3 months. A Likert scale from 1 “not a barrier” to 5 “significant barrier” was used to assess providers’ barriers to educating families about the diagnosis of concussion. Providers selected 4 or 5 on the scale for the following barriers and frequencies: inadequate training to educate 16% (95% CI: 11%–23%), inadequate time to educate 15% (95% CI: 12%–24%), and not my role to educate 1% (95% CI: 0.4%–5%). Ninety-six percent (95% CI: 91%–98%) of providers without a provider decision support tool (such as a clinical pathway or protocol) specific to concussion, and 100% (95% CI: 94%–100%) of providers without discharge instructions specific to concussion believed these resources would be helpful.
CONCLUSIONS: Although pediatric primary care and emergency medicine providers regularly care for concussion patients, they may not have adequate training or infrastructure to systematically diagnose and manage these patients. Specific provider education, decision support tools, and patient information could help enhance and standardize concussion management.
- CI —
- confidence interval
- EM —
- emergency medicine
- mTBI —
- mild traumatic brain injury
- PCPs —
- primary care providers
What's Known on This Subject:
Previous studies have revealed misconceptions among pediatric patients, their families, and athletic coaches surrounding concussion. Little is known about pediatric primary care and emergency medicine providers’ attitudes and beliefs about diagnosis and management of this mild traumatic brain injury.
What This Study Adds:
Although pediatric primary care and emergency medicine providers regularly care for concussion patients and value their role in management, they may not have adequate training or infrastructure to systematically diagnose and manage these patients.
Concussion is a mild traumatic brain injury (mTBI) with pathophysiological sequelae induced by biomechanical forces,1 and ∼100 000 to 140 000 children present to the emergency department for concussion each year in the United States.2,3 Although the majority of concussion patients recover quickly, these seemingly “mild” injuries can have prolonged physical, cognitive, and emotional symptoms.4 Immediate recognition of this brain injury, prompt initiation of treatment in the form of cognitive and physical rest, and ongoing surveillance of symptoms are important to promote recovery.5 Although emergency departments and primary care practices frequently serve as the first point of entry for the care of pediatric concussion patients, medical providers in these settings may not have adequate training or management tools necessary to provide standardized and evidence-based evaluation and management. In 2 recent surveys,6,7 pediatricians and other primary care providers (PCPs) self-identified as the appropriate source to provide follow-up for patients with mTBI, although they lacked the appropriate continuing medical education and neurocognitive testing infrastructure to adequately evaluate pediatric patients with mTBI. Although many institutions have concussion “specialists” to follow-up patients with severe or prolonged symptoms, emergency medicine (EM) providers and PCPs provide the initial evaluation for the overwhelming majority of injured patients. In some settings, PCPs may also be the only available resource for ongoing concussion management. As more concussions are being identified, it is critical for these providers to be familiar and comfortable with initial concussion management and coordinate care with concussion specialists as necessary.
The goal of the current study was to determine general pediatric and EM providers’ self-reported knowledge, practices, and beliefs surrounding concussion diagnosis and management in a single, large pediatric care network.
Methods
The survey was a cross-sectional, confidential survey that was identified as exempt from review by our institutional review board. Consent was implied by completion of the survey. Potential survey participants were identified from the Children’s Hospital of Philadelphia Care Network and Emergency Department e-mail lists. Eligible subjects included attending physicians, fellow physicians, and nurse practitioners in the emergency department, and attending physicians, nurse practitioners, and physician assistants in the primary care network. Participants were excluded if they were not a practicing clinician or if they were a study coinvestigator. The electronic survey was designed and distributed by using the electronic software Research Electronic Data Capture hosted at the Children’s Hospital of Philadelphia Center for Bioinformatics.8 After the initial E-mail distribution of the survey, 2 reminders were sent approximately every 2 weeks to eligible subjects who had not responded. There was no incentive for participation. The survey included multiple-choice, Likert-scale, and free-text questions. Outcomes measured included demographics, self-reported knowledge about concussion (through 3 scenario-based items, and symptom lists adapted from the Acute Concussion Evaluation9), concussion management practices (treatment, referral patterns to specialists after a provider visit), and barriers to certain aspects of concussion management.
Data Analysis
Data from the Research Electronic Data Capture database were downloaded into Stata (Version 10.0, StataCorp, College Station, TX). Standard descriptive summaries were used. Comparisons of categorical variables between subgroups were made by using the χ2 test or the Fisher’s exact test, depending on the size of the sample. Comparisons of continuous variables were completed by using independent t tests or nonparametric tests depending on normality of distribution. Other associations were explored by using univariate analysis.
Results
There were 145 responses from 276 eligible providers, resulting in a 53% response rate. Demographics of the participants are shown in Table 1.
Demographics of Survey Respondents (N = 145)
In the previous 3 months, 91% (95% confidence interval [CI]: 86%–95%) had cared for at least 1 concussion patient at an acute presentation (ie, first medical visit within 24 hours after injury) or nonacute presentation (ie, first medical visit >24 hours after injury, persistent symptoms after an initial acute visit, or routine re-evaluation for a diagnosed concussion).
The patterns of, and reasons for, referrals to concussion specialists are shown in Table 2. The majority of providers (92%) had referred at least 1 concussion patient in the previous 3 months after the initial visit. PCPs were more likely to refer because they were not as comfortable with management or did not have adequate time or resources, when compared with EM providers. When compared with PCPs, EM providers were more likely to refer because they did not perceive it to be their role or did not believe their setting was appropriate for ongoing management. The most frequent referral for all providers was to a sports medicine specialist. EM providers more frequently referred to a trauma surgeon or clinic, and PCPs more frequently referred to a neurologist or neuropsychologist.
Provider Patterns of and Reasons for Referral After Initial Visit for Concussion
When presented with a list of historical items, signs, symptoms, and physical examination findings, respondents were asked if each was mandatory, supportive, or not relevant to concussion. Notable findings included the following percentages of respondent stating the item was “not relevant” to the diagnosis: abnormal eye tracking 17% (95% CI: 11%–24%), difficulty concentrating 11% (7%–17%), vestibular disturbance 9% (5%–15%) decline in school performance 6% (3%–11%), and sensitivity to light or noise 6% (3%–11%).
Table 3 reveals bulleted, abbreviated versions of the 2 full concussion scenarios (1 patient with subtle concussion symptoms, the other with more overt symptoms), and responses for likelihood of diagnosis, treatment, and referral for concussion. Nearly all the providers indicated that both patients had a concussion. EM physicians were more likely to refer patients to a concussion specialist (eg, sports medicine, trauma, or neurology provider) than a primary care physician (P < .0001 for both scenarios).
Scenario-based Case Responses for Likelihood of Diagnosis, Treatment, and Referral for Concussion
Table 4 lists the barriers for providers to completing formal neurocognitive testing, educating families about the diagnosis, recommending appropriate time to resume school, and prescribing a gradual return to play protocol for sports. The majority of providers felt that there was inadequate time and training to complete neurocognitive testing in their setting. EM providers were more likely to not consider neurocognitive testing their role compared with PCPs (45% vs 13%, P < .001).
Pediatric Primary Care and EM Barriers Surrounding Concussion Management
Of the 104 providers without access to a provider decision support tool (such as a clinical pathway or protocol) specific to concussion, 96% (95% CI: 91%–98%) believed these resources would be helpful. Similarly, 100% (95% CI: 94%–100%) of the 57 providers without discharge instructions specific to concussion also believed decision support tools would be helpful. There were no significant differences in responses based on gender or years in practice.
Discussion
The results demonstrate that although pediatric primary care and EM providers regularly care for concussion patients and value their role in management, they may not have adequate training or infrastructure to systematically diagnose and manage these patients. Because the emergency department and primary care settings provide the initial medical care for pediatric patients with concussion, it is critical that these providers have the necessary tools to ensure the delivery of standardized, evidence-based management.
Although the majority of providers identified subtle mood and cognitive changes after head trauma as concussion in the patient scenarios, some providers did not believe abnormal eye tracking, difficulty concentrating, vestibular disturbance, decline in school performance, and sensitivity to light or noise were related to concussion. These more subtle signs of concussion may present in isolation and thus may be the only indication that a child has sustained the injury. As a result, their systematic assessment in initial and follow-up physical examinations related to concussion is important and should be supplemented with continuing education surrounding concussion evaluation and management.
Knowledge and misconceptions about concussion have been assessed in other populations. Studies have revealed that concussion symptoms may be underidentified by parents10,11 and underreported by children.12 Various surveys of youth sports’ coaches have revealed that many have misconceptions about concussion, which can be improved with education.13,14 Another study of high school rugby players revealed limited knowledge surrounding return to play guidelines after a concussion.15 A recent survey of the general public revealed that some individuals have inaccurate knowledge about concussion, including not categorizing it as a brain injury.16 Given this inconsistent knowledge, providers must consider utilizing tools to systematically evaluate, treat, and educate patients with mTBI and their families about this “silent” injury. The current survey also revealed that although all providers believed that educating patients and families about concussion was their role, PCPs were more likely than EM providers to view recommending return to school and play as part of their management responsibility. It is likely that this reflects the challenges of EM providers to predict on an initial visit when a patient’s symptoms will resolve and when they will be ready to return. This is consistent with a recent national survey of pediatricians who also believed this was their role, despite not always being comfortable with the role due to inadequate concussion-specific education or resources.6
The majority of providers (92%) had referred patients to a concussion specialist within the previous 3 months. The reasons for EM providers’ referral were intuitive; they do not provide ongoing management of these children and it is not their role. However, for more minor concussion, it is possible that EM providers could potentially shift their referral patterns to PCPs or even potentially initiate formal cognitive rest and return to school plans, with the recommendation of follow-up only if symptoms do not improve. In contrast to the EM providers, PCPs referred because of inadequate comfort, time, or resources. These barriers could potentially be alleviated by continuing medical education, management guidelines, and provider support systems. Such a change in the role of primary care physicians in managing certain diagnoses is not unprecedented. Attention deficit hyperactivity disorder, which was historically managed by mental health care providers, is now routinely managed by PCPs as a result of increased awareness, training, and decision support tools.17,18
By including concussion in graduate medical education and continuing medical education curricula, providers can enhance their knowledge of evidence-based and practical concussion principles.19,20 Standardized evaluation and decision-making tools can serve as helpful adjuncts to education. An example of such a toolkit designed by the Centers for Disease Control and Prevention and targeting coaches and parents of children with sports-related concussion demonstrated increased awareness about symptoms and sequelae of concussion, in addition to knowledge transfer about concussion management to others.21 The Centers for Disease Control and Prevention has developed additional online concussion tools in this “Heads Up” series designed for health care providers, schools, families, and patients.22 The provider resources include concussion evaluation forms, fact sheets, care plans, and patient handouts. Incorporating these tools into existing electronic health record infrastructure can enhance and automate evidence-based decision support by providers,23 which was found to be highly valued by the participants in the current survey. Additional contemporary technologies such as mobile phone applications24 and social networking25,26 can also serve as promising modes to assist diagnosis and management of concussion. All interventions designed to enhance knowledge and change behavior should be rooted in behavioral theory models designed to assess the underlying beliefs and attitudes of the individual,27 and rigorously evaluated to maximize effectiveness.
As of April 2012, 35 states have adopted youth concussion laws that include some combination of education, removal from physical activity, and clearance by a health professional before returning to play.28 These laws will undoubtedly dramatically increase the number of concussion patients who need clearance by a health care provider. This will require providers to have evidence-based decision models that allow for systematic and safe clearance before a concussion patient can resume sports.29 Possibly even more imperative is the need for a return to school protocol based on regular assessment of symptoms by the patient, family, and provider.30
Our study did have limitations that must be considered. Although the response rate was fairly high, there could still have been potential response and selection biases. However, the results still revealed a deficit in training and infrastructure in the target audience of PCPs and EM providers. Similarly, certain subjective survey language about attitudes and comfort may have been subject to various interpretations by respondents. Finally, this study was conducted in a single-care network, which could limit the generalizability of the results.
Conclusions
It is critical that pediatric primary care and EM providers consistently diagnose concussion, initiate treatment in the form of cognitive and physical rest, and provide the necessary return to school and return to play protocols. Although these providers care for concussion patients and value their role in management, they may not have adequate training or infrastructure to systematically diagnose and manage these patients. Provider education, decision support tools, and patient information specific to concussion could help enhance and standardize concussion management. Education and provider tools that integrate behavioral psychology and technology should be evaluated, ideally through randomized trials.
Acknowledgments
We thank Michael L. Nance, MD, Douglas J. Wiebe, PhD, Nicole Ryan, MD, Roni L. Robinson, RN, MSN, CRNP, Kristen L. Kohser, LMSW, Alexander McGinley, BS, and Xuemei Zhang, MS, for their assistance with the project.
Footnotes
- Accepted July 11, 2012.
- Address correspondence to Mark R. Zonfrillo, MD, MSCE, Division of Emergency Medicine, The Children’s Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA 19104. E-mail: zonfrillo{at}email.chop.edu
Dr Zonfrillo conceptualized and designed the study, completed data analysis, interpreted the data, drafted the initial article, critically reviewed the article, and approved the final article as submitted; and Drs Master, Grady, Winston, Callahan, and Arbogast significantly contributed to study conception and design, interpreted the data, critically reviewed the article, and approved the final article as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: This study was supported by The Children’s Hospital of Philadelphia Department of Pediatrics Chair’s Initiative.
References
- Copyright © 2012 by the American Academy of Pediatrics
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