Disparities in Adherence to Concussion Clinical Care Recommendations in a Pediatric Population

Abstract

Objective: To characterize the relationship of sociodemographic factors to adherence to provider recommendations for pediatric concussion. Setting: Primary care (PC) practices within the Children's Hospital of Philadelphia network. Participants: Patients aged 5 to 18 years old who presented to any PC site for concussion from September 26, 2019, to December 31, 2019. Design: Retrospective medical record review. Main measures: The primary outcome was adherence to follow-up recommendations as defined by (1) continued follow-up until provider clearance to return to full activity; (2) no more than 2 no-show visits; and (3) for those referred to specialty care (SC), attending at least 1 visit. We compared adherence by race/ethnicity, insurance, age, sex, injury mechanism, and repeat head injury using bivariate and multivariate analyses. A secondary outcome of referral to SC was compared by sociodemographic factors. Results: A total of 755 patients were included. Overall, 80.5% of the patients met adherence criteria. Following adjustment, non-Hispanic Black patients and publicly insured/self-pay patients were less likely to adhere to recommendations than non-Hispanic White patients (adjusted odds ratio [AOR] = 0.60; 95% CI, 0.37-1.00) and privately insured patients (AOR = 0.48; 95% CI, 0.30-0.75), respectively. When assessing differences in referral to SC, non-Hispanic Black patients and publicly insured/self-pay patients were more likely to receive a referral than their non-Hispanic White peers (OR = 1.56; 95% CI, 1.00-2.45) and privately insured patients (OR = 1.56; 95% CI, 1.05-2.32), respectively. Conclusion: This study highlights disparities in adherence to concussion care recommendations, with non-Hispanic Black and publicly insured/self-pay patients less likely to adhere to follow-up recommendations than non-Hispanic White and privately insured patients, respectively. These disparities may impact recovery trajectories. Future studies should aim to identify specific individual- and system-level barriers preventing adherence to care in order to ultimately inform targeted interventions to achieve equity in care delivery and outcomes.

The effect of a home exercise program on visio-vestibular function in concussed pediatric patients

“…However, some patients experience barriers to access these therapies throughout their full course of care. Mohammed and colleagues (14) found that disparities are evident when examining adherence to concussion care recommendations, some of which may be addressed by using a cost-effective and equitable at-home program. Our findings indicate at-home exercise programs prescribed within 28 days of injury may be effective in reducing overall concussion symptoms.…”

“…Current concussion consensus statements recommend a multi-faceted approach to concussion management (3), particularly in pediatric patients due to an increased vulnerability to injury (4), longer average recovery (5), and the inclusion of additional stakeholders (i.e., school nurses, teachers, parents) (5) relative to adult patients. Additionally, active rehabilitation programs, including vision and vestibular therapies, are recommended for the treatment of adolescent concussion (3,(6)(7)(8); however, barriers to specialized concussion care, including financial barriers (9,10), access to health care (11), or socioeconomic health disparities (12)(13)(14), prevent patients from accessing the relevant concussion care to optimize their recovery. There is a need to further explore cost-effective and equitable approaches to active concussion management in a pediatric population.…”

Social Determinants of Health and Traumatic Brain Injury: Implications for Rehabilitation Service Delivery and Outcomes

“…Members of latent classes characterized by greater systematic disadvantage (eg, minoritized racial/ethnic group; older age) were less likely to access inpatient rehabilitation and were at greater risk for mortality. Finally, Mohammed et al 11 examined racial and ethnic disparities in adherence to primary care provider recommendations for concussion in the pediatric population. They found that non-Hispanic Black patients and those who did not have private insurance were less likely to adhere to recommendations relative to non-Hispanic White patients and those with private insurance.…”

“…For example, several studies revealed racial disparities in TBI care and outcomes. 7,8,10,11 However, race and ethnicity are socially constructed categories that serve as surrogate measures of historical and structural marginalization that may shape TBI care and recovery in myriad, dynamic, and mutually reinforcing ways. 20 As such, including indicators of race and ethnicity alone may be necessary, yet insufficient, for understanding the specific mechanisms underlying disparities in TBI service delivery and recovery.…”

“…Although findings presented add to evidence of disparities in TBI care and outcomes across SDoH, what continues to be urgently needed is empirical support for purported theories explaining such disparities—many of which were advanced by authors of studies included in this issue. For example, several studies revealed racial disparities in TBI care and outcomes 7,8,10,11. However, race and ethnicity are socially constructed categories that serve as surrogate measures of historical and structural marginalization that may shape TBI care and recovery in myriad, dynamic, and mutually reinforcing ways 20.…”