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International Journal of Adolescent Medicine and Health. 2017; 20170070
Khalida Itriyeva1 / Ronald Feinstein2 / Linda Carmine2
Pediatric providers’ attitudes and practices regarding concussion diagnosis and management 1
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Division of Adolescent Medicine, Cohen Children’s Medical Center, Northwell Health System, Hofstra Northwell School of Medicine, 410 Lakeville Road Suite 108, New Hyde Park, NY 11042, USA, Phone: +(516) 465-3270, Fax: (516) 465-5299, E-mail: [email protected]. http://orcid.org/0000-0001-6156-3884. 2 Division of Adolescent Medicine, Cohen Children’s Medical Center, Northwell Health System, Hofstra Northwell School of Medicine, New Hyde Park, NY, USA Abstract: Background: Concussions, a form of mild traumatic brain injury, are a current “hot topic” in sports and medicine, with current research focusing on diagnosis, treatment, and the long-term effects of repeated concussions on development of chronic traumatic encephalopathy. Concussions represent 8.9% of all high school athletic injuries, and pediatricians see many of these patients in their practices, however evolving guidelines and recommendations have resulted in varying practices among providers. Objective: To assess how local pediatricians in New York Chapter 2 of the American Academy of Pediatrics (AAP) diagnose and treat concussion patients, and to evaluate the need for continuing education in this area. Design and methods: Survey Monkey™ was used to query providers regarding their diagnosis and treatment of concussion patients. A total of three emails containing a link to the 22 question multiple-choice survey were sent to AAP Chapter 2 members between January 2015 and June 2015. The survey was adapted and modified with permission from one previously used by “Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB. Pediatric providers’ self-reported knowledge, practices, and attitudes about concussion. Pediatrics. 2012;130:1120–5”. Results: We received 115 responses from 1436 potential participants to whom the survey link was sent, resulting in an 8% response rate. We excluded subspecialists from our data analysis, resulting in data from 95 primary care pediatricians. Of the PCPs 98.7% reported seeing at least one child or adolescent with a concussion in the previous 12 months and 76.6% reported referring some or all of their concussion patients for ongoing management. The most common reason for referral was “I am not always comfortable with management” and the most common subspecialist referral was to a neurologist. Most providers reported that they did not use any guidelines for management (58.3%) and only 57.4% were familiar with the New York State Education Department concussion guidelines. Almost half reported inadequate training in performing neurocognitive assessments (48.6%). Most were comfortable educating families about the diagnosis of concussion (81.7%), as well as recommending the appropriate time to resume school (70.4%) and prescribing and monitoring a return to play protocol (62%). A total of 84.3% also responded, however, that they would be interested in a webinar for a continuing medical education(CME) credit focused on concussion diagnosis and management. Conclusions: Most pediatric providers care for patients who have suffered a concussion, however many identify barriers to diagnosis and treatment, which results in patients being referred to subspecialists for further management. Many providers are also unfamiliar with, or do not use, published concussion guidelines and report varying practices in treatment of concussion patients due to evolving recommendations. This study demonstrates that there is a need for further education for pediatric providers who see patients with concussion. Keywords: concussion, concussion guidelines, concussion practices, primary care pediatrics DOI: 10.1515/ijamh-2017-0070 Received: April 28, 2017; Accepted: June 11, 2017
Introduction Concussions, a form of mild traumatic brain injury, are a current “hot topic” in sports, medicine, and the media, with research focusing on diagnosis, management, and the long-term effects of concussions on the potential development of chronic traumatic encephalopathy (CTE) and other cognitive sequelae [1]. In recent years, Khalida Itriyeva is the corresponding author. ©2017 Walter de Gruyter GmbH, Berlin/Boston.
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increased public awareness of the prevalence of concussion in organized sports has led many states to pass concussion laws to protect young athletes. In May 2009, Washington became the first state to pass legislation on concussions and, by February 2014, all 50 states and the District of Columbia had passed state concussion laws pertaining to student athletes [2]. Increased interest in concussions has also been prevalent in the medical community, with a multitude of published guidelines from a variety of professional societies emerging over the past 15 years. Published guidelines focus on the diagnosis and management of concussion based on expert consensus; however, there remains a lack of good quality data on the optimal duration of physical and cognitive rest for athletes who have suffered a concussion [3], [4], [5]. Previous studies have demonstrated wide variability in the usage rates of published guidelines among healthcare providers caring for concussion patients, with a range of 14.6%–80% [6], [7], [8], [9], [10], [11]. Variation in practice among providers most commonly resulted from confusion surrounding the many available guidelines, or a lack of awareness of the guidelines [11]. As greater numbers of patients are being identified with possible concussion, pediatric primary care providers are increasingly seeing concussion patients in their offices, and are thus becoming increasingly responsible for diagnosis and management [12], [13], [14]. This pattern is likely to continue as identification of concussions among children and adolescents continues to rise. An estimated 8.9% of all high school athletic injuries are concussions [15], and the Centers for Disease Control and Prevention (CDC) estimates that between 2001 and 2009, the number of annual traumatic brain injury (TBI)-related emergency department (ED) visits increased by 62%, from 153,375 to 248,418 [16]. Notably, the highest rates were among males aged 10–19 years. Other studies have also demonstrated an increase in concussions among youth [13], [17], [18]. In a study of over 8 million members of a large private-payer insurance group in the United States, Zhang et al. [17] reported a 60% increase in concussion incidence from 2007 to 2014. Of these, 32% were adolescents aged 10–19 years. In a comprehensive study using three national databases, Bryan et al. [13] reported that between 1.1 and 1.9 million sports- and recreation-related concussions occur in United States youth aged ≤18 years every year, resulting in 377,978 outpatient visits and roughly 140,000 ED visits. Importantly, in a study that investigated point of health care entry for children and adolescents with concussion, Arbogast et al. [14] found that almost 82% of patients had their first concussion visit within primary care, while only 11.7% presented to the emergency department or urgent care setting. As pediatric primary care providers increasingly become responsible for diagnosing and managing the growing number of concussion patients, it is vital that they receive the appropriate training and resources to take care of these patients. Previous studies have highlighted the variation in practice and inconsistent use of guidelines among providers caring for concussion patients, but many of these studies focused on emergency department and general practitioners, with few surveying pediatric providers [6], [7], [8], [10], [19], [20]. The aim of our study was to investigate how primary care pediatricians in a local New York chapter of the American Academy of Pediatrics (AAP) diagnose and manage concussion patients. Specifically, we were interested in providers’ referral patterns to specialists, use of published guidelines, barriers to care, and interest in continuing medical education (CME) on the topic of concussions. We hypothesized that pediatric providers who did not use any published concussion guidelines, were not familiar with the New York State Education Department (NYSED) concussion guidelines, and were unfamiliar or did not use neurocognitive assessments would be more likely to refer patients to a concussion specialist.
Methods Procedure A cross-sectional study of pediatrician members of the American Academy of Pediatrics (AAP) New York Chapter 2 was conducted using an online multiple-choice survey. A series of three emails containing a brief description of the study and a link to the survey were sent by AAP New York Chapter 2 administration to 1436 chapter members over a 6-month period between January and June 2015. Participants were informed that the survey was being conducted by the AAP New York Chapter 2 Committee on Youth and Adolescence (COYA), and that involvement in the study was voluntary and anonymous. The study qualified for exempt status by our institutional review board and consent was implied by completion of the survey. There was no compensation for study participants.
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Participants Participants included members of the AAP New York Chapter 2 who had active e-mail addresses on file with the chapter administration. Out of 1616 members, 1436 had active e-mail addresses. Geographically, members included pediatricians from four counties, Brooklyn and Queens (in New York City) and Nassau and Suffolk (on Long Island). Survey respondents included primary care pediatricians and pediatric specialists. As the target population of our study was primary care pediatricians, participants were excluded from data analysis if they identified themselves as a pediatric specialist on the questionnaire.
Questionnaire
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Survey questions were adapted and revised with permission from a study previously conducted by Zonfrillo et al. [19]. The final survey contained a total of 22 multiple choice questions that were uploaded to Survey Monkey® , an online survey tool, by the AAP New York Chapter 2 administration. Participants were asked if they identified as a primary care provider or a specialist, and their type of practice setting (i.e. private practice, hospital-based, emergency department, or urgent care center). They were then asked if their practice involved seeing children and adolescents who may have suffered a concussion, and how many concussion patients ages 5 and older they had cared for in the previous 12 months. A series of questions subsequently assessed respondents’ referral patterns of their concussion patients, with a specific focus on the frequency of referral, reasons for referral, and specialist(s) patients were referred to. Participants were then queried on their use of concussion guidelines and, specifically, if they were familiar with the NYSED guidelines for concussion management in school settings. Pediatricians were also asked about the barriers they faced in the management of concussion patients. Barrier questions focused on completing neurocognitive assessments, educating families about the diagnosis of concussion, recommending the appropriate time to resume school, and initiating a return to play protocol. Pediatricians were then asked when they typically allow patients to return to school and physical activities, and about concussion resources available to them, such as provider decision support tools, discharge instructions for patients, and informational patient handouts. Three demographic questions at the end of the survey asked participants about their gender, years since their last classroom-based medical education, and location of their practice. Finally, participants were asked if they would be interested in a continuing medical education (CME) activity focused on concussion diagnosis and management. Participants had the capability to skip questions that they did not wish to answer and could terminate the survey at any time. Participants were provided with links to online concussion resources at the conclusion of the survey.
Data analysis We used the FREQ procedure, available on SAS/STAT® software, to analyze participants’ responses to survey questions. The FREQ procedure created data tables for each question in the survey. Data collected included the frequency with which each answer was chosen within a multiple choice question, the percentage of respondents who chose a particular answer, and the frequency with which each question was skipped by participants. A question regarding participants’ use of concussion guidelines was dichotomized to a “Yes” or “No” answer from a multiple-choice answer that included a list of various guidelines. A Fisher’s exact test was then used to determine whether an association existed between the question “Do you use any guidelines to manage your concussion patients?” and a question asking providers to describe their referral patterns of concussion patients. Similarly, a Fisher’s exact test was used to determine if there was an association between providers’ familiarity with the NYSED concussion guidelines and their frequency of referral to concussion specialists. Finally, we compared providers’ use of and familiarity with neurocognitive assessments to their frequency of referral to concussion specialists. A p-value of 0.05 was used to indicate significance. The data analysis for our study was generated using SAS/STAT® software, Version 9.4 of the SAS System for Windows. SAS and all other SAS Institute Inc. product or service names are registered trademarks or trademarks of SAS Institute Inc. (Cary, NC, USA).
Results We received 116 responses from 1436 AAP New York Chapter 2 members to whom the email with a link to the survey was sent, resulting in an 8.1% response rate. Of the 116 respondents, 20 identified as pediatric subBrought to you by | University of Gothenburg Authenticated Download Date | 9/29/17 2:53 AM
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specialists, and were excluded from our data analysis. One of the 116 respondents did not answer any survey questions, and was also excluded from data analysis. Our final data analysis included 95 pediatric primary care providers, who represented 81.9% of survey respondents. Table 1 summarizes the demographic data for the 95 respondents. The majority of providers were in private practice (54.7%), female (58%), and had completed their last classroom-based medical education 20+ years ago (52.9%). It is worth noting that not all survey respondents answered every question, thus the percentages reported reflect the total number of participants who replied to each individual question. Table 1: Demographics of study participants. Primary practice setting Private practice Hospital-based Urgent care center Other Total respondents Gender Male Female Total respondents Years since last classroom-based medical education 0–4 5–9 10–14 15–19 20+ Total respondents
n
%
52 36 1 6 95
54.7 37.9 1.1 6.3
29 40 69
42.0 58.0
14 8 8 3 37 70
20.0 11.4 11.4 4.3 52.9
Almost all (97.5%) of the respondents reported that they see children and adolescents who may have had a concussion, and of those with a positive response, almost all (98.7%) had cared for at least one pediatric concussion patient in the previous year (Table 2).
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Table 2: Participants’ experience caring for concussion patients. Do you see children and adolescents who may have had a concussion?
n
Yes 78 No 2 Total respondents 80 In the past 12 months, how many patients ages 5 years and older have you cared for with a concussion? 0 1 1–5 38 6–10 16 >10 23 Total respondents 78
% 97.5 2.5 1.3 48.7 20.5 29.5
Table 3 summarizes participants’ reported referral patterns of concussion patients. Most providers (76.6%) reported referring some or all of their concussion patients to a specialist. The most common reason for referral was not always being comfortable with management (41.3%). The second and third most common reasons for referral were inadequate resources for management and setting not always being appropriate for management; each was endorsed by 39.1% of respondents. The most common specialist that concussion patients were referred to was a neurologist (79.7% of respondents), followed by a concussion clinic/center (40.7% of respondents). Table 3: Participants’ referral patterns of concussion patients. Referral to specialists Do not refer any concussion patients Refer some concussion patients Refer all concussion patients Total respondents
4
n
%
18 54 5 77
23.4 70.1 6.5
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Reasons for referrala Not always comfortable with management Do not always have adequate resources for management My setting is not always appropriate for management Do not always have adequate time for management I believe all patients with a concussion should see a specialist Total respondents Specialists concussion patients were referred toa Neurologist Concussion clinic/center Neuropsychologist Sports medicine/orthopedics physician or clinic Trauma surgeon or clinic Neurosurgeon Physical medicine and rehabilitation specialist Chiropractor Acupuncturist or complementary medicine specialist Other Total respondents
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a
Itriyeva et al.
19
41.3
18
39.1
18
39.1
11
23.9
8
17.4
46 47 24 4 3
79.7 40.7 6.8 5.1
3 1 1
5.1 1.7 1.7
0 0
0.0 0.0
1 59
1.7
Participants were asked to “select all that apply” for these two questions, thus each participant may have chosen more than one answer.
The majority of providers reported that they did not use any guidelines in the management of their concussion patients (58.3%) and only 57.4% were familiar with the NYSED concussion guidelines (Table 4). Respondents also identified barriers to management of their concussion patients (Table 5). Notably, 59.5% of providers were not familiar with and did not perform neurocognitive assessments, 28.4% were familiar with but did not perform neurocognitive assessments, and only 12.2% were familiar with and performed neurocognitive assessments (Table 6). Almost half (48.6%) felt that they had inadequate training to perform a neurocognitive assessment. However, most pediatric providers were comfortable educating families about the diagnosis of concussion (81.7%), as well as recommending the appropriate time to resume school (70.4%). Fewer responded that prescribing and monitoring a return to play protocol was not a barrier for them (62%). In total, 21.1% of respondents reported that recommending the appropriate time to resume school was a barrier for them due to lack of training, and 23.9% reported the same for prescribing and monitoring a return to play protocol. Table 4: Use of guidelines. Do you use any guidelines to manage your concussion patients?a American Academy of Neurology American Medical Society for Sports Medicine Zurich Consensus Statement Colorado Medical Society Cantu None of the above Total respondents Are you familiar with the NYSED concussion guidelines? Yes No Total respondents a
n
%
10 9
16.7 15.0
6 3 2 35 60
10.0 5.0 3.3 58.3
39 29 68
57.4 42.6
Participants were asked to select all that apply.
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Table 5: Barriers to concussion management. Not a barrier, %
Not enough training, %
Not enough time, %
Not my role, %
12.9
48.6
17.1
4.3
81.7
11.3
7.0
0.0
70.4
21.1
2.8
5.6
62.0
23.9
7.0
7.0
Completing a neurocognitive screening assessment Educating families about the diagnosis of concussion Recommending the appropriate time to resume school Prescribing and monitoring a return to play protocol
Table 6: Neurocognitive assessments. Do you perform or are familiar with any neurocognitive assessments? Yes – familiar with and perform Yes – familiar with but do not perform No – not familiar with and do not perform Total respondents
n
%
9 21
12.2 28.4
44
59.5
74
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Most (87.3%) respondents correctly answered that they allow a concussion patient to return to physical activity/sports when the patient is completely asymptomatic. However, responses varied on return to learning/school, with 52.2% of respondents allowing patients to return to learning/school when their symptoms were improving, 26.9% allowed it when patients were completely asymptomatic, and 1.5% allowed it 7 days after concussion, irrespective of symptoms. Some (19.4%) respondents did not limit school attendance at all after a concussion (Table 7). Table 7: Participants’ management of concussion patients. When do you typically allow a patient to return to physical activity or sports?
n
When they are completely 55 asymptomatic When their symptoms are improving 6 Seven days after their concussion, 2 irrespective of their symptoms Total respondents 63 When do you typically allow a patient to return to learning/school? I do not limit school attendance after 13 concussion When they are completely 18 asymptomatic When their symptoms are improving 35 Seven days after their concussion, 1 irrespective of their symptoms Total respondents 67 Provider decision support tool (i.e. clinical pathway, algorithm, protocol, template) for concussion Yes – it is available to me and it is 16 helpful Yes – it is available to me, but it is not 1 helpful
6
%
87.3 9.5 3.2
19.4 26.9 52.2 1.5
22.9
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No – it is not available to me and it 50 would be helpful No – it is not available to me and it 3 would not be helpful Total respondents 70 After-visit summaries, discharge instructions, or patient handouts for concussion Yes – it is available to me and it is 33 helpful Yes – it is available to me, but it is not 6 helpful No – it is not available to me and it 31 would be helpful No – it is not available to me and it 0 would not be helpful Total respondents 70
71.4 4.3
47.1 8.6 44.3 0
In terms of resources, 94.1% of respondents who had a provider decision support tool for concussion found it helpful, and 94.3% of respondents who did not have a provider decision support tool for concussion felt it would be helpful. Responses were similar for concussion-related after-visit summaries, discharge instructions, and patient handouts. Most (84.6%) providers to whom these resources were available found them helpful, and 100% of providers to whom these resources were not available felt they would be helpful. Finally, 84.3% of pediatricians responded that they would be interested in a webinar for CME credit focused on concussion diagnosis and management (Table 8).
Table 8: Continuing medical education (CME). Would you be interested in a webinar for CME credit with archive capability focused on concussion diagnosis and management?
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Yes No Total respondents
n
%
59 11 70
84.3 15.7
Further analysis of the data using a Fisher’s exact test revealed no significant association between the dichotomized question “Do you use any guidelines to manage your concussion patients?” and “After patients visit your setting for concussion, describe your referral pattern to a concussion specialist for ongoing management” (p = 0.8711). Similarly, there was no significant association between providers’ familiarity with the NYSED concussion guidelines and their frequency of referral to concussion specialists (p = 0.4159). Finally, a comparison of providers’ use of and familiarity with neurocognitive assessments to their frequency of referral to concussion specialists was not found to be statistically significant (p = 0.2084).
Discussion Primary care pediatricians are increasingly tasked with caring for patients who have suffered a concussion. Our study confirms that the vast majority of pediatricians in two New York City boroughs and Long Island are seeing concussion patients in their practice setting. However, pediatric providers do not consistently have the supportive tools and resources that are often needed to manage these patients. Our study also demonstrates that most pediatricians surveyed do not consistently use published guidelines in the management of their concussion patients and, although most are comfortable with managing concussion patients, the vast majority are also interested in continuing medical education on the topic of concussion. We found that most pediatric providers surveyed refer some or all of their concussion patients to specialists, consistent with the findings of Zonfrillo et al. [19]. However, while Zonfrillo found that primary care pediatricians were most likely to refer patients to a sports medicine physician or clinic, our respondents were most likely to refer patients to a neurologist. The observed difference may, in part, be related to the resources available in a specific geographic area, and which specialists manage concussion patients within a particular health system. Reasons for referral in our study, including lack of comfort, time, resources, and inappropriate setting were consistent with the previous study’s findings. Brought to you by | University of Gothenburg Authenticated Download Date | 9/29/17 2:53 AM
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We also found that 41.7% of pediatric providers use any published guidelines in the management of their concussion patients, consistent with previous studies that showed usage rates of published guidelines among healthcare providers between 14.6% and 80% [6], [7], [8], [9], [10], [11]. Notably, only 57.4% of respondents were familiar with the state-wide NYSED concussion guidelines, which were originally published in June 2012 and revised in January 2014. We also found that the majority of providers were not familiar with and did not perform neurocognitive assessments, with a lack of training representing the most common barrier to completing a neurocognitive assessment. This finding was consistent with previous studies that demonstrated barriers to primary care providers’ use of neurocognitive assessments [9], [19]. Most pediatricians in our study were comfortable educating families about the diagnosis of concussion, a finding that is consistent with prior studies [6], [19], as well as recommending the appropriate time to return to school. However, just over 20% reported that they did not have adequate training to recommend the appropriate time to resume school, consistent with the findings of Zonfrillo et al. [19], where 25% of primary care pediatricians reported inadequate training. Additionally, only 62% of our study respondents reported that prescribing and monitoring a return to play protocol was not a barrier, with almost 24% reporting a lack of training as the most common barrier. This percentage is slightly less than the 30% who identified lack of training as a barrier in the study by Zonfrillo et al. [19]. Our results are also comparable to the findings of Carl and Kinsella [6], who found that only 69% of pediatricians who managed
International Journal of Adolescent Medicine and Health. 2017; 20170070
Khalida Itriyeva1 / Ronald Feinstein2 / Linda Carmine2
Pediatric providers’ attitudes and practices regarding concussion diagnosis and management 1
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Division of Adolescent Medicine, Cohen Children’s Medical Center, Northwell Health System, Hofstra Northwell School of Medicine, 410 Lakeville Road Suite 108, New Hyde Park, NY 11042, USA, Phone: +(516) 465-3270, Fax: (516) 465-5299, E-mail: [email protected]. http://orcid.org/0000-0001-6156-3884. 2 Division of Adolescent Medicine, Cohen Children’s Medical Center, Northwell Health System, Hofstra Northwell School of Medicine, New Hyde Park, NY, USA Abstract: Background: Concussions, a form of mild traumatic brain injury, are a current “hot topic” in sports and medicine, with current research focusing on diagnosis, treatment, and the long-term effects of repeated concussions on development of chronic traumatic encephalopathy. Concussions represent 8.9% of all high school athletic injuries, and pediatricians see many of these patients in their practices, however evolving guidelines and recommendations have resulted in varying practices among providers. Objective: To assess how local pediatricians in New York Chapter 2 of the American Academy of Pediatrics (AAP) diagnose and treat concussion patients, and to evaluate the need for continuing education in this area. Design and methods: Survey Monkey™ was used to query providers regarding their diagnosis and treatment of concussion patients. A total of three emails containing a link to the 22 question multiple-choice survey were sent to AAP Chapter 2 members between January 2015 and June 2015. The survey was adapted and modified with permission from one previously used by “Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB. Pediatric providers’ self-reported knowledge, practices, and attitudes about concussion. Pediatrics. 2012;130:1120–5”. Results: We received 115 responses from 1436 potential participants to whom the survey link was sent, resulting in an 8% response rate. We excluded subspecialists from our data analysis, resulting in data from 95 primary care pediatricians. Of the PCPs 98.7% reported seeing at least one child or adolescent with a concussion in the previous 12 months and 76.6% reported referring some or all of their concussion patients for ongoing management. The most common reason for referral was “I am not always comfortable with management” and the most common subspecialist referral was to a neurologist. Most providers reported that they did not use any guidelines for management (58.3%) and only 57.4% were familiar with the New York State Education Department concussion guidelines. Almost half reported inadequate training in performing neurocognitive assessments (48.6%). Most were comfortable educating families about the diagnosis of concussion (81.7%), as well as recommending the appropriate time to resume school (70.4%) and prescribing and monitoring a return to play protocol (62%). A total of 84.3% also responded, however, that they would be interested in a webinar for a continuing medical education(CME) credit focused on concussion diagnosis and management. Conclusions: Most pediatric providers care for patients who have suffered a concussion, however many identify barriers to diagnosis and treatment, which results in patients being referred to subspecialists for further management. Many providers are also unfamiliar with, or do not use, published concussion guidelines and report varying practices in treatment of concussion patients due to evolving recommendations. This study demonstrates that there is a need for further education for pediatric providers who see patients with concussion. Keywords: concussion, concussion guidelines, concussion practices, primary care pediatrics DOI: 10.1515/ijamh-2017-0070 Received: April 28, 2017; Accepted: June 11, 2017
Introduction Concussions, a form of mild traumatic brain injury, are a current “hot topic” in sports, medicine, and the media, with research focusing on diagnosis, management, and the long-term effects of concussions on the potential development of chronic traumatic encephalopathy (CTE) and other cognitive sequelae [1]. In recent years, Khalida Itriyeva is the corresponding author. ©2017 Walter de Gruyter GmbH, Berlin/Boston.
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increased public awareness of the prevalence of concussion in organized sports has led many states to pass concussion laws to protect young athletes. In May 2009, Washington became the first state to pass legislation on concussions and, by February 2014, all 50 states and the District of Columbia had passed state concussion laws pertaining to student athletes [2]. Increased interest in concussions has also been prevalent in the medical community, with a multitude of published guidelines from a variety of professional societies emerging over the past 15 years. Published guidelines focus on the diagnosis and management of concussion based on expert consensus; however, there remains a lack of good quality data on the optimal duration of physical and cognitive rest for athletes who have suffered a concussion [3], [4], [5]. Previous studies have demonstrated wide variability in the usage rates of published guidelines among healthcare providers caring for concussion patients, with a range of 14.6%–80% [6], [7], [8], [9], [10], [11]. Variation in practice among providers most commonly resulted from confusion surrounding the many available guidelines, or a lack of awareness of the guidelines [11]. As greater numbers of patients are being identified with possible concussion, pediatric primary care providers are increasingly seeing concussion patients in their offices, and are thus becoming increasingly responsible for diagnosis and management [12], [13], [14]. This pattern is likely to continue as identification of concussions among children and adolescents continues to rise. An estimated 8.9% of all high school athletic injuries are concussions [15], and the Centers for Disease Control and Prevention (CDC) estimates that between 2001 and 2009, the number of annual traumatic brain injury (TBI)-related emergency department (ED) visits increased by 62%, from 153,375 to 248,418 [16]. Notably, the highest rates were among males aged 10–19 years. Other studies have also demonstrated an increase in concussions among youth [13], [17], [18]. In a study of over 8 million members of a large private-payer insurance group in the United States, Zhang et al. [17] reported a 60% increase in concussion incidence from 2007 to 2014. Of these, 32% were adolescents aged 10–19 years. In a comprehensive study using three national databases, Bryan et al. [13] reported that between 1.1 and 1.9 million sports- and recreation-related concussions occur in United States youth aged ≤18 years every year, resulting in 377,978 outpatient visits and roughly 140,000 ED visits. Importantly, in a study that investigated point of health care entry for children and adolescents with concussion, Arbogast et al. [14] found that almost 82% of patients had their first concussion visit within primary care, while only 11.7% presented to the emergency department or urgent care setting. As pediatric primary care providers increasingly become responsible for diagnosing and managing the growing number of concussion patients, it is vital that they receive the appropriate training and resources to take care of these patients. Previous studies have highlighted the variation in practice and inconsistent use of guidelines among providers caring for concussion patients, but many of these studies focused on emergency department and general practitioners, with few surveying pediatric providers [6], [7], [8], [10], [19], [20]. The aim of our study was to investigate how primary care pediatricians in a local New York chapter of the American Academy of Pediatrics (AAP) diagnose and manage concussion patients. Specifically, we were interested in providers’ referral patterns to specialists, use of published guidelines, barriers to care, and interest in continuing medical education (CME) on the topic of concussions. We hypothesized that pediatric providers who did not use any published concussion guidelines, were not familiar with the New York State Education Department (NYSED) concussion guidelines, and were unfamiliar or did not use neurocognitive assessments would be more likely to refer patients to a concussion specialist.
Methods Procedure A cross-sectional study of pediatrician members of the American Academy of Pediatrics (AAP) New York Chapter 2 was conducted using an online multiple-choice survey. A series of three emails containing a brief description of the study and a link to the survey were sent by AAP New York Chapter 2 administration to 1436 chapter members over a 6-month period between January and June 2015. Participants were informed that the survey was being conducted by the AAP New York Chapter 2 Committee on Youth and Adolescence (COYA), and that involvement in the study was voluntary and anonymous. The study qualified for exempt status by our institutional review board and consent was implied by completion of the survey. There was no compensation for study participants.
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Participants Participants included members of the AAP New York Chapter 2 who had active e-mail addresses on file with the chapter administration. Out of 1616 members, 1436 had active e-mail addresses. Geographically, members included pediatricians from four counties, Brooklyn and Queens (in New York City) and Nassau and Suffolk (on Long Island). Survey respondents included primary care pediatricians and pediatric specialists. As the target population of our study was primary care pediatricians, participants were excluded from data analysis if they identified themselves as a pediatric specialist on the questionnaire.
Questionnaire
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Survey questions were adapted and revised with permission from a study previously conducted by Zonfrillo et al. [19]. The final survey contained a total of 22 multiple choice questions that were uploaded to Survey Monkey® , an online survey tool, by the AAP New York Chapter 2 administration. Participants were asked if they identified as a primary care provider or a specialist, and their type of practice setting (i.e. private practice, hospital-based, emergency department, or urgent care center). They were then asked if their practice involved seeing children and adolescents who may have suffered a concussion, and how many concussion patients ages 5 and older they had cared for in the previous 12 months. A series of questions subsequently assessed respondents’ referral patterns of their concussion patients, with a specific focus on the frequency of referral, reasons for referral, and specialist(s) patients were referred to. Participants were then queried on their use of concussion guidelines and, specifically, if they were familiar with the NYSED guidelines for concussion management in school settings. Pediatricians were also asked about the barriers they faced in the management of concussion patients. Barrier questions focused on completing neurocognitive assessments, educating families about the diagnosis of concussion, recommending the appropriate time to resume school, and initiating a return to play protocol. Pediatricians were then asked when they typically allow patients to return to school and physical activities, and about concussion resources available to them, such as provider decision support tools, discharge instructions for patients, and informational patient handouts. Three demographic questions at the end of the survey asked participants about their gender, years since their last classroom-based medical education, and location of their practice. Finally, participants were asked if they would be interested in a continuing medical education (CME) activity focused on concussion diagnosis and management. Participants had the capability to skip questions that they did not wish to answer and could terminate the survey at any time. Participants were provided with links to online concussion resources at the conclusion of the survey.
Data analysis We used the FREQ procedure, available on SAS/STAT® software, to analyze participants’ responses to survey questions. The FREQ procedure created data tables for each question in the survey. Data collected included the frequency with which each answer was chosen within a multiple choice question, the percentage of respondents who chose a particular answer, and the frequency with which each question was skipped by participants. A question regarding participants’ use of concussion guidelines was dichotomized to a “Yes” or “No” answer from a multiple-choice answer that included a list of various guidelines. A Fisher’s exact test was then used to determine whether an association existed between the question “Do you use any guidelines to manage your concussion patients?” and a question asking providers to describe their referral patterns of concussion patients. Similarly, a Fisher’s exact test was used to determine if there was an association between providers’ familiarity with the NYSED concussion guidelines and their frequency of referral to concussion specialists. Finally, we compared providers’ use of and familiarity with neurocognitive assessments to their frequency of referral to concussion specialists. A p-value of 0.05 was used to indicate significance. The data analysis for our study was generated using SAS/STAT® software, Version 9.4 of the SAS System for Windows. SAS and all other SAS Institute Inc. product or service names are registered trademarks or trademarks of SAS Institute Inc. (Cary, NC, USA).
Results We received 116 responses from 1436 AAP New York Chapter 2 members to whom the email with a link to the survey was sent, resulting in an 8.1% response rate. Of the 116 respondents, 20 identified as pediatric subBrought to you by | University of Gothenburg Authenticated Download Date | 9/29/17 2:53 AM
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specialists, and were excluded from our data analysis. One of the 116 respondents did not answer any survey questions, and was also excluded from data analysis. Our final data analysis included 95 pediatric primary care providers, who represented 81.9% of survey respondents. Table 1 summarizes the demographic data for the 95 respondents. The majority of providers were in private practice (54.7%), female (58%), and had completed their last classroom-based medical education 20+ years ago (52.9%). It is worth noting that not all survey respondents answered every question, thus the percentages reported reflect the total number of participants who replied to each individual question. Table 1: Demographics of study participants. Primary practice setting Private practice Hospital-based Urgent care center Other Total respondents Gender Male Female Total respondents Years since last classroom-based medical education 0–4 5–9 10–14 15–19 20+ Total respondents
n
%
52 36 1 6 95
54.7 37.9 1.1 6.3
29 40 69
42.0 58.0
14 8 8 3 37 70
20.0 11.4 11.4 4.3 52.9
Almost all (97.5%) of the respondents reported that they see children and adolescents who may have had a concussion, and of those with a positive response, almost all (98.7%) had cared for at least one pediatric concussion patient in the previous year (Table 2).
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Table 2: Participants’ experience caring for concussion patients. Do you see children and adolescents who may have had a concussion?
n
Yes 78 No 2 Total respondents 80 In the past 12 months, how many patients ages 5 years and older have you cared for with a concussion? 0 1 1–5 38 6–10 16 >10 23 Total respondents 78
% 97.5 2.5 1.3 48.7 20.5 29.5
Table 3 summarizes participants’ reported referral patterns of concussion patients. Most providers (76.6%) reported referring some or all of their concussion patients to a specialist. The most common reason for referral was not always being comfortable with management (41.3%). The second and third most common reasons for referral were inadequate resources for management and setting not always being appropriate for management; each was endorsed by 39.1% of respondents. The most common specialist that concussion patients were referred to was a neurologist (79.7% of respondents), followed by a concussion clinic/center (40.7% of respondents). Table 3: Participants’ referral patterns of concussion patients. Referral to specialists Do not refer any concussion patients Refer some concussion patients Refer all concussion patients Total respondents
4
n
%
18 54 5 77
23.4 70.1 6.5
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Reasons for referrala Not always comfortable with management Do not always have adequate resources for management My setting is not always appropriate for management Do not always have adequate time for management I believe all patients with a concussion should see a specialist Total respondents Specialists concussion patients were referred toa Neurologist Concussion clinic/center Neuropsychologist Sports medicine/orthopedics physician or clinic Trauma surgeon or clinic Neurosurgeon Physical medicine and rehabilitation specialist Chiropractor Acupuncturist or complementary medicine specialist Other Total respondents
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a
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19
41.3
18
39.1
18
39.1
11
23.9
8
17.4
46 47 24 4 3
79.7 40.7 6.8 5.1
3 1 1
5.1 1.7 1.7
0 0
0.0 0.0
1 59
1.7
Participants were asked to “select all that apply” for these two questions, thus each participant may have chosen more than one answer.
The majority of providers reported that they did not use any guidelines in the management of their concussion patients (58.3%) and only 57.4% were familiar with the NYSED concussion guidelines (Table 4). Respondents also identified barriers to management of their concussion patients (Table 5). Notably, 59.5% of providers were not familiar with and did not perform neurocognitive assessments, 28.4% were familiar with but did not perform neurocognitive assessments, and only 12.2% were familiar with and performed neurocognitive assessments (Table 6). Almost half (48.6%) felt that they had inadequate training to perform a neurocognitive assessment. However, most pediatric providers were comfortable educating families about the diagnosis of concussion (81.7%), as well as recommending the appropriate time to resume school (70.4%). Fewer responded that prescribing and monitoring a return to play protocol was not a barrier for them (62%). In total, 21.1% of respondents reported that recommending the appropriate time to resume school was a barrier for them due to lack of training, and 23.9% reported the same for prescribing and monitoring a return to play protocol. Table 4: Use of guidelines. Do you use any guidelines to manage your concussion patients?a American Academy of Neurology American Medical Society for Sports Medicine Zurich Consensus Statement Colorado Medical Society Cantu None of the above Total respondents Are you familiar with the NYSED concussion guidelines? Yes No Total respondents a
n
%
10 9
16.7 15.0
6 3 2 35 60
10.0 5.0 3.3 58.3
39 29 68
57.4 42.6
Participants were asked to select all that apply.
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Table 5: Barriers to concussion management. Not a barrier, %
Not enough training, %
Not enough time, %
Not my role, %
12.9
48.6
17.1
4.3
81.7
11.3
7.0
0.0
70.4
21.1
2.8
5.6
62.0
23.9
7.0
7.0
Completing a neurocognitive screening assessment Educating families about the diagnosis of concussion Recommending the appropriate time to resume school Prescribing and monitoring a return to play protocol
Table 6: Neurocognitive assessments. Do you perform or are familiar with any neurocognitive assessments? Yes – familiar with and perform Yes – familiar with but do not perform No – not familiar with and do not perform Total respondents
n
%
9 21
12.2 28.4
44
59.5
74
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Most (87.3%) respondents correctly answered that they allow a concussion patient to return to physical activity/sports when the patient is completely asymptomatic. However, responses varied on return to learning/school, with 52.2% of respondents allowing patients to return to learning/school when their symptoms were improving, 26.9% allowed it when patients were completely asymptomatic, and 1.5% allowed it 7 days after concussion, irrespective of symptoms. Some (19.4%) respondents did not limit school attendance at all after a concussion (Table 7). Table 7: Participants’ management of concussion patients. When do you typically allow a patient to return to physical activity or sports?
n
When they are completely 55 asymptomatic When their symptoms are improving 6 Seven days after their concussion, 2 irrespective of their symptoms Total respondents 63 When do you typically allow a patient to return to learning/school? I do not limit school attendance after 13 concussion When they are completely 18 asymptomatic When their symptoms are improving 35 Seven days after their concussion, 1 irrespective of their symptoms Total respondents 67 Provider decision support tool (i.e. clinical pathway, algorithm, protocol, template) for concussion Yes – it is available to me and it is 16 helpful Yes – it is available to me, but it is not 1 helpful
6
%
87.3 9.5 3.2
19.4 26.9 52.2 1.5
22.9
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No – it is not available to me and it 50 would be helpful No – it is not available to me and it 3 would not be helpful Total respondents 70 After-visit summaries, discharge instructions, or patient handouts for concussion Yes – it is available to me and it is 33 helpful Yes – it is available to me, but it is not 6 helpful No – it is not available to me and it 31 would be helpful No – it is not available to me and it 0 would not be helpful Total respondents 70
71.4 4.3
47.1 8.6 44.3 0
In terms of resources, 94.1% of respondents who had a provider decision support tool for concussion found it helpful, and 94.3% of respondents who did not have a provider decision support tool for concussion felt it would be helpful. Responses were similar for concussion-related after-visit summaries, discharge instructions, and patient handouts. Most (84.6%) providers to whom these resources were available found them helpful, and 100% of providers to whom these resources were not available felt they would be helpful. Finally, 84.3% of pediatricians responded that they would be interested in a webinar for CME credit focused on concussion diagnosis and management (Table 8).
Table 8: Continuing medical education (CME). Would you be interested in a webinar for CME credit with archive capability focused on concussion diagnosis and management?
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Yes No Total respondents
n
%
59 11 70
84.3 15.7
Further analysis of the data using a Fisher’s exact test revealed no significant association between the dichotomized question “Do you use any guidelines to manage your concussion patients?” and “After patients visit your setting for concussion, describe your referral pattern to a concussion specialist for ongoing management” (p = 0.8711). Similarly, there was no significant association between providers’ familiarity with the NYSED concussion guidelines and their frequency of referral to concussion specialists (p = 0.4159). Finally, a comparison of providers’ use of and familiarity with neurocognitive assessments to their frequency of referral to concussion specialists was not found to be statistically significant (p = 0.2084).
Discussion Primary care pediatricians are increasingly tasked with caring for patients who have suffered a concussion. Our study confirms that the vast majority of pediatricians in two New York City boroughs and Long Island are seeing concussion patients in their practice setting. However, pediatric providers do not consistently have the supportive tools and resources that are often needed to manage these patients. Our study also demonstrates that most pediatricians surveyed do not consistently use published guidelines in the management of their concussion patients and, although most are comfortable with managing concussion patients, the vast majority are also interested in continuing medical education on the topic of concussion. We found that most pediatric providers surveyed refer some or all of their concussion patients to specialists, consistent with the findings of Zonfrillo et al. [19]. However, while Zonfrillo found that primary care pediatricians were most likely to refer patients to a sports medicine physician or clinic, our respondents were most likely to refer patients to a neurologist. The observed difference may, in part, be related to the resources available in a specific geographic area, and which specialists manage concussion patients within a particular health system. Reasons for referral in our study, including lack of comfort, time, resources, and inappropriate setting were consistent with the previous study’s findings. Brought to you by | University of Gothenburg Authenticated Download Date | 9/29/17 2:53 AM
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We also found that 41.7% of pediatric providers use any published guidelines in the management of their concussion patients, consistent with previous studies that showed usage rates of published guidelines among healthcare providers between 14.6% and 80% [6], [7], [8], [9], [10], [11]. Notably, only 57.4% of respondents were familiar with the state-wide NYSED concussion guidelines, which were originally published in June 2012 and revised in January 2014. We also found that the majority of providers were not familiar with and did not perform neurocognitive assessments, with a lack of training representing the most common barrier to completing a neurocognitive assessment. This finding was consistent with previous studies that demonstrated barriers to primary care providers’ use of neurocognitive assessments [9], [19]. Most pediatricians in our study were comfortable educating families about the diagnosis of concussion, a finding that is consistent with prior studies [6], [19], as well as recommending the appropriate time to return to school. However, just over 20% reported that they did not have adequate training to recommend the appropriate time to resume school, consistent with the findings of Zonfrillo et al. [19], where 25% of primary care pediatricians reported inadequate training. Additionally, only 62% of our study respondents reported that prescribing and monitoring a return to play protocol was not a barrier, with almost 24% reporting a lack of training as the most common barrier. This percentage is slightly less than the 30% who identified lack of training as a barrier in the study by Zonfrillo et al. [19]. Our results are also comparable to the findings of Carl and Kinsella [6], who found that only 69% of pediatricians who managed
