Response rate patterns in adolescents with concussion using mobile health and remote patient monitoring (Preprint)

Abstract

BACKGROUND Concussion is a common adolescence injury that can result in a constellation of symptoms, negatively affecting their academic performance, neurobiological development, and quality of life. Mobile health (mHealth) technology has been shown its promising role in managing real-time symptoms. However, there is limited evidence about mHealth engagement in adolescents with concussion during recovery course. OBJECTIVE To determine the response rate and response rate patterns in concussed adolescents reporting their daily symptoms through mHealth technology; and examine the effect of time-, demographic- and injury-related characteristics on response rate patterns. METHODS Participants aged between 11 – 18 years were recruited from the concussion program of a tertiary care academic medical center and a suburban school’s athletic teams. They were asked to report their daily symptoms using a mobile app. Participants were prompted to complete the Post-Concussion Symptom Inventory (PCSI) 3 times (i.e., morning, afternoon, and evening) per day for 4 weeks following enrollment. The primary outcome was response rate pattern over time since enrollment. Time-of-day-, demographic-, and injury-related differences in reporting behaviors were compared using Wilcoxon rank sum tests. RESULTS Fifty-six participants were enrolled (age 15.3 ± 1.9 years, 57.1% female). Median response rate across all days of app usage in the evening was 37.0% which was significantly higher than morning (21.2%) or afternoon (26.4%) (P < .001). Median daily response was significantly different by sex (53.8% in females vs 42.0% in males, P < .01), days since injury to app usage (54.1% for participants starting to use app > 7 days since injury vs 38.0% for those ≤ 7 days, P < .01), and concussion history (57.4% for participants with history of at least one prior concussion vs 42.3% for those without concussion history, P = .03). There were no significant differences in median daily response by age (47.5% for 11 — 14 years vs 50.9% for 15 — 18 years, P = .34). Differences by injury mechanism (39.6% for sports- and recreation-related injury vs 30.6% for non-sports-and-recreation-related injury, P = .04) and initial symptom burden (40.9% for PCSI scores > the median score of 47 vs 31.9% for PCSI score ≤ median score, P = .04) were evident in the evening response rates. CONCLUSIONS Evening may be the optimal time to prompt for daily concussion symptom assessment among concussed adolescents compared with morning or afternoon. Multiple demographic- and injury-related characteristics were associated with higher response rates, including females, more than one week from injury to beginning of mHealth monitoring, history of at least one previous concussion, relatively higher initial symptom burden, and injury caused by sports and recreation activities. Future studies may consider incentive strategies or adaptive digital concussion assessments to increase response rates in the population with low engagement.