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research-article2014

CPJXXX10.1177/0009922814526979Clinical PediatricsCarl and Kinsella

Article

Pediatricians’ Knowledge of Current Sports Concussion Legislation and Guidelines and Comfort With Sports Concussion Management: A CrossSectional Study

Clinical Pediatrics 2014, Vol. 53(7) 689­–697 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814526979 cpj.sagepub.com

Rebecca L. Carl, MD1,2 and Sarah B. Kinsella, MD1,2

Abstract Background. Sports-related concussions disproportionately affect young athletes. The primary objective of our study was to determine Illinois pediatricians’ level of familiarity with state concussion legislation and with published consensus guidelines for sports concussion diagnosis and treatment. We also sought to determine pediatricians’ knowledge regarding concussion management and comfort treating sports concussion patients. Methods. This was a cross-sectional survey of pediatrician members of the Illinois Chapter of the American Academy of Pediatrics. Results. Few general pediatricians (26.6%, n = 42) were “very familiar” or “somewhat familiar” with the recently passed Illinois state concussion legislation. Only 14.6% (n = 23) of general pediatrician respondents use concussion consensus guidelines in their practice. Pediatricians were generally very knowledgeable about concussions; only 5 out of 19 knowledge-based items were answered incorrectly by more than 25% of the study participants. Conclusions. General pediatricians are knowledgeable about concussions but most are not well aware of state concussion legislation and concussion consensus guidelines. Keywords sports medicine, concussion, legislation

Introduction Over the past decade, the medical community has recognized that sports-related concussions are an important public health concern. Concussions occur when a blow or a transmitted force to the head causes neuronal dysfunction and leads to symptoms. Symptoms can include cognitive changes, somatic symptoms, psychological symptoms, and sleep disturbance.1 Sports concussions appear to affect children and adolescents disproportionately. From 2001 to 2009, nearly 200 000 individuals sought treatment for sports-related concussions in emergency departments each year; 70.5% of these patients were between 10 and 19 years old.2 Children and adolescents also take longer to recover from concussions than adults.3,4 Since 2009, 41 states and the District of Columbia have passed sports concussion legislation; most of these laws mandate that young athletes suspected of sustaining a concussion be immediately removed from athletic activities. Many states require that an athlete receive clearance from a physician prior to return to sports.5 The

governor of Illinois signed sports concussion legislation into law in July 2011.6 In 2001, a multidisciplinary group of concussion experts met for the First International Conference on Concussion in Sport; following this meeting, these specialists published the Consensus Statement on Concussion in Sport.7 The third and fourth versions of these guidelines were published following meetings in Zurich, Switzerland, and are often referred to as the Zurich guidelines.1,8 The consensus statements summarize research on sports concussion and provide guidelines for caring for athletes following concussion.

1

Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA 2 Northwestern University, Feinberg School of Medicine, Chicago, IL, USA Corresponding Author: Rebecca L. Carl, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Avenue, Box 69, Chicago, IL, 60611, USA. Email: [email protected]

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The number of young athletes seeking medical attention for concussion has increased steadily over the past decade.2 With the recently increased awareness about the long-term effects of multiple concussions and increasing numbers of children participating in athletics, pediatricians can expect to care for a larger volume of concussion patients. The primary objective of our study was to determine Illinois pediatricians’ level of familiarity with state concussion legislation and the Zurich concussion guidelines. A secondary goal was to evaluate pediatricians’ knowledge regarding concussion epidemiology, diagnosis and management and their comfort treating sports concussion patients. We also sought to compare pediatricians in different practices settings and physicians who manage concussion frequently with those who treat concussion less frequently.

Methods Subjects The Institutional Review Board at the Ann & Robert H. Lurie Children’s Hospital of Chicago approved this study. Because this was a survey study with minimal risk to participants and a consent form would link responses to each participant, the institutional review board agreed to waive the requirement of written informed consent. Completion of the survey constituted implicit consent to participate in the study. The target population was pediatricians in the state of Illinois. The source population was Illinois pediatrician members of the Illinois Chapter of the American Academy of Pediatrics (ICAAP). ICAAP approved this study and provided a letter granting us permission to survey the organization’s members. ICAAP periodically sends brief newsletters via e-mail to members. In late October 2011, 3 months after Illinois’s concussion legislation was signed into law, the newsletter included an invitation to participate in our study with a hyperlink to the site hosting the online survey. In early November 2011, 9 days following the initial e-mail invitation, the ICAAP mailing included a reminder asking members to complete the survey. The newsletters were sent to 2388 e-mail addresses. ICAAP does not remove e-mail addresses from its member database unless specifically requested by an addressee. Also, ICAAP does not have a way to track the number of e-mails returned as “undeliverable.” Therefore, we were unable to determine which addresses were currently in use.

Survey We created a 29-item survey based on information highlighted in the Zurich guidelines (see the appendix); the

survey was not validated. The majority of the survey items were designed to assess physicians’ knowledge of currently accepted criteria for concussion diagnosis and concussion treatment. The survey included question on medical practice demographics, frequency of concussion management, and level of comfort with various aspect of concussion management. We also asked physicians what types of resources they would like to have available to help them treat patients with concussion. We developed the self-administered survey used in this study using the information provided in the 2009 Zurich guidelines as the basis for the knowledge questions.8 The hyperlink in the ICAAP mailing led physicians to an online survey hosted on the Web site Zoomerang. The survey included an introduction letter that explained the objectives, risks, and benefits of the study. The letter stated that the study was voluntary and we would not collect identifying information. We informed potential subjects that we planned to share the aggregate data with ICAAP to assist the organization in the development of educational resources for pediatricians. We did not provide any incentive for survey completion.

Analysis This was a pilot study; we did not conduct a power analysis. We used SPSS version 21 to analyze the data. We compared pediatricians who reported treating at least one patient with concussion per month with those who managed concussions less frequently. We dichotomized the responses to the question “How would you describe your familiarity with concussion legislation in the State of Illinois?” into 2 categories: subjects who were very familiar or somewhat familiar with the legislation and subjects who were unaware of the legislation or unaware of the details and status of the bills. We also dichotomized the responses to the question “How would you describe your familiarity with the Consensus Statement on Concussion in Sport?” into the group of respondents who were very familiar with the guidelines (those who used them in the practice and those who did not) and the respondents who were somewhat or unfamiliar with the guidelines. Additionally, we dichotomized the responses to the 3 questions asking pediatricians to describe their level of comfort with concussion diagnosis and management into the categories “very” or “somewhat” comfortable and “not very” or “not at all” comfortable. We also examined the differences in responses to the questions on legislation, consensus guidelines and comfort with diagnosis by practice type (academic or community based). We employed cross-tabulation to create contingency tables for each comparison. We then used Pearson χ2 test or Fisher’s exact test to evaluate the statistical

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E-mail opened but did not follow hyperlink to survey n=310 E-mail opened n=571 E-mail addresses in ICAAP database n=2248

Non-completion n=29 Accessed survey n=261

E-mail never opened n=1677

Complete responses n=222

Excluded from analysis Resident physician n=18 Retired from practice n=9 Sub-specialty physician n=35 Primary specialty other than pediatrics n=2

Completed survey, included in analysis n=158

Figure 1.  Flow chart of subject recruitment and response rate.

significance of differences in response rates between groups. The level of significance (α) was set at .05.

Results Out of 2488 e-mails sent, 571 were opened. 261 potential respondents accessed the survey; 222 physicians completed the survey; the response rate was 8.9%. The survey ended after the first question for the 9 retired physician and 18 resident physician respondents. In planning the study, we intended to examine responses from subspecialty physicians who were likely to treat patients with concussions. Because the numbers of subspecialty respondents was small (35 total subspecialists, including 9 emergency medicine physicians, 1 pediatric neurologist, 1 adolescent specialist, and 1 sports medicine physician), we excluded these physicians and 2 family medicine physicians from our analysis. We included 2 physicians certified in both in internal medicine and pediatrics in the final analysis. Figure 1 illustrates the study participant selection and response rate. We analyzed the responses of the 158 general pediatrician study participants. Table 1 shows the physicians’ length of time in practice and frequency of managing concussion patients. Of these respondents, 26.6% reported being “very familiar” or “somewhat familiar” with the Illinois concussion legislation. In response to the question, “How would you describe your familiarity with The Consensus Statement on Concussion in Sport?” 14.6% of the pediatricians responded that they were “very familiar” with the guidelines. Most pediatricians felt somewhat or very comfortable recognizing the symptoms of concussion (94.9%), reviewing concussion treatment with families (91.8%), and providing written documentation regarding return to play following concussion (77.8%). Pediatricians who reported managing at least one concussion per month were more likely to be familiar with Illinois concussion legislation and reported

being more comfortable with recognizing and managing concussions (Table 2). Pediatricians practicing in academic and community settings reported similar levels of awareness of legislation and guidelines and similar levels of comfort with diagnosing concussions and counseling patients and families (Table 3). Overall, pediatricians were very well informed about sports concussion. Of the 19 questions designed to gauge concussion knowledge, there were only 5 items answered incorrectly by greater than 25% of respondents (Table 4). When asked which resources they would like to have available to help them care for patients with concussion, all of the general pediatricians selected at least one response; pediatricians most frequently requested a Web site listing available resources for pediatricians (74.1%) and a review article in print (67.7%).

Discussion We surveyed Illinois pediatricians to determine their awareness of recently enacted state concussion legislation. Most pediatricians were unfamiliar with the details of the new law and nearly one third did not know that concussion legislation existed. Although 38.6% of pediatricians see at least one patient with concussion per month, most did not use the Zurich concussion document to guide treatment. Pediatricians who frequently treat concussion patients reported greater familiarity with state concussion legislation and were more likely to be comfortable with diagnosing concussions, reviewing treatment plans with families and providing written return-to-sport instructions. Pediatricians practicing in community and academic settings exhibited similar levels of awareness of Illinois concussion legislation and concussion consensus guidelines and were equally comfortable diagnosing and counseling patients with sports concussion. Study

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Table 1.  Demographic Information Regarding General Pediatrician Members of the Illinois Chapter of the American Academy of Pediatrics Who Completed a 2011 Survey on Sports Concussion. Percentage (Total = 158)  

Academic Primary Care (n = 26)

Community-Based Primary Care (n = 132)

19.2 23.1 19.2 38.4

  22.0 9.8 13.6 54.5  

7.7 19.2 23.1 50.0

3.0 37.9 29.5 29.5

Years in practice  

Pediatricians' knowledge of current sports concussion legislation and guidelines and comfort with sports concussion management: a cross-sectional study.

Sports-related concussions disproportionately affect young athletes. The primary objective of our study was to determine Illinois pediatricians' level...
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