Point of Health Care Entry for Youth With Concussion Within a Large Pediatric Care Network

Abstract

IMPORTANCE Previous epidemiologic research on concussions has primarily been limited to patient populations presenting to sport concussion clinics or to emergency departments (EDs) and to those high school age or older. By examining concussion visits across an entire pediatric health care network, a better estimate of the scope of the problem can be obtained.OBJECTIVE To comprehensively describe point of entry for children with concussion, overall and by relevant factors including age, sex, race/ethnicity, and payor, to quantify where children initially seek care for this injury. DESIGN, SETTING, AND PARTICIPANTSIn this descriptive epidemiologic study, data were collected from primary care, specialty care, ED, urgent care, and inpatient settings. The initial concussion-related visit was selected and variation in the initial health care location (primary care, specialty care, ED, or hospital) was examined in relation to relevant variables. All patients aged 0 to 17 years who received their primary care from The Children's Hospital of Philadelphia's (CHOP) network and had 1 or more in-person clinical visits for concussion in the CHOP unified electronic health record (EHR) system (July 1, 2010, to June 30, 2014) were selected. MAIN OUTCOMES AND MEASURES Frequency of initial concussion visits at each type of health care location. Concussion visits in the EHR were defined based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes indicative of concussion.RESULTS A total of 8083 patients were included (median age, 13 years; interquartile range, 10-15 years). Overall, 81.9% (95% CI, 81.1%-82.8%; n = 6624) had their first visit at CHOP within primary care, 5.2% (95% CI, 4.7%-5.7%; n = 418) within specialty care, and 11.7% (95% CI, 11.0%-12.4%; n = 947) within the ED. Health care entry varied by age: 52% (191/368) of children aged 0 to 4 years entered CHOP via the ED, whereas more than three-quarters of those aged 5 to 17 years entered via primary care (5-11 years: 1995/2492; 12-14 years: 2415/2820; and 15-17 years: 2056/2403). Insurance status also influenced the pattern of health care use, with more Medicaid patients using the ED for concussion care (478/1290 Medicaid patients [37%] used the ED vs 435/6652 private patients [7%] and 34/141 self-pay patients [24%]). CONCLUSIONS AND RELEVANCEThe findings suggest estimates of concussion incidence based solely on ED visits underestimate the burden of injury, highlight the importance of the primary care setting in concussion care management, and demonstrate the potential for EHR systems to advance research in this area.

Variations in Mechanisms of Injury for Children with Concussion

“…Visits were defined as when the healthcare provider selected an International Classification of Diseases, Ninth Revision Clinical Modification (ICD-9-CM) diagnosis code indicative of a concussion 23 (Appendix; available at www.jpeds.com). Each patient was counted only once, using their initial visit, defined as the first clinical encounter for a concussion within the study period.…”

“…Last, we classified a healthcare system point of entry for concussion care for each CHOP network patient. 23 …”

Service Delivery in the Healthcare and Educational Systems for Children Following Traumatic Brain Injury: Gaps in Care

“…Children with mild head injuries may present to clinical locations other than the ED, such as pediatricians’ offices, 60 or may not seek care at all, making it difficult to accurately estimate the true incidence of injury, which in turn complicates the understanding of overall outcomes. 61–63 More severe TBI requires comprehensive medical management that can include assessment for structural problems such as brain swelling, bleeding or pressure on the brain, brain imaging, and/or transfer to a pediatric trauma center.…”

What is the difference in concussion management in children as compared with adults? A systematic review

“…About 4 million children are estimated to present annually to emergency departments (EDs) worldwide with concussion,1–3 which is estimated to represent only 12% of children with concussion 4. This suggests that annually about 33 million children worldwide sustain a concussion.…”