1. Khalida Itriyeva, MD, Ronald Feinstein, MD, Linda Carmine, MD
Pediatric Providers’ Attitudes and Practices Regarding Concussion Diagnosis and Management
Khalida Itriyeva, MD, Ronald Feinstein, MD, Linda Carmine, MD
Division of Adolescent Medicine, Cohen Children’s Medical Center, Northwell Health, New Hyde Park, NY
Hofstra Northwell School of Medicine, Hempstead, NY
Results
Barriers to Concussion Management
Not a barrier (%)
Not Enough Training (%)
Not Enough Time (%)
Not My Role (%)
Completing a neurocognitive screening assessment
12.9
48.6
17.1
4.3
Educating families about the diagnosis of concussion
81.7
11.3
7.0
0.0
Recommending the appropriate time to resume school
70.4
21.1
2.8
5.6
Prescribing and monitoring a return to play protocol
62.0
23.9
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 will see many of these patients in their practices.
Numerous evolving guidelines and recommendations on diagnosis and treatment have resulted in varying practices among providers.
Concussion Care Practices n
In the past 12 months, how many patients ages 5 years and older have you cared for with a concussion? 1
1-5 38
6-10 16
Greater than 10 23
After patients visit your setting for concussion, describe your referral pattern to a concussion specialist for ongoing management:
I do not refer any of my concussion patients 18
I refer some of my concussion patients 54
I refer all of my concussion patients 5
What are the reasons that you refer patients for ongoing management of concussion? (Select all that apply)
I am not always comfortable with management 19
I do not always have adequate resources for management
My setting is not always appropriate for management
I do not always have adequate time for management 11
I believe all patients with a concussion should see a specialist 8
If you have referred any of your concussion patients to a specialist for ongoing management, please select all of the specialists you have referred them to:
Neurologist 47
Concussion clinic/center 24
Neuropsychologist 4
Trauma surgeon or clinic 3
Sports medicine/orthopedics physician or clinic
Neurosurgeon
Physical medicine and rehabilitation specialist
Chiropractor
Acupuncturist or complementary medicine specialist
Do you use any of the following guidelines to manage your concussion patients? Please check all that apply:
American Academy of Neurology 10
American Medical Society for Sports Medicine 9
Zurich Consensus Statement 6
Colorado Medical Society
Cantu 2
None of the above 35
Are you familiar with the New York State Education Department concussion guidelines?
Yes 39 No 29
Do you perform or are familiar with any neurocognitive assessments?
Yes – Familiar with and perform
Yes – Familiar with but do not perform 21
No – Not familiar with and do not perform 44
Summary
Objective
115 responses were received, including 95 primary care pediatricians (82.6%­) whose data was used for analysis.
98.7% of PCPs had seen 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 that patients were referred to was a neurologist.
Most participants reported that they did not use any guidelines in management of their concussion patients (58.3%) and only 57.4% were familiar with the New York State Education Department concussion guidelines.
Respondents also identified barriers to management of their concussion patients. Notably, almost half felt that they had inadequate training to perform a neurocognitive screening assessment.
Most pediatric providers said they 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 for sports (62%).
Most (84.3%) also responded, however, that they would be interested in a webinar for Continuing Medical Education (CME) credit focused on concussion diagnosis and management.
The objective of our study was to assess how local pediatricians in New York Chapter 2 of the American Academy of Pediatrics (AAP) diagnose and treat pediatric patients who have suffered a concussion and to evaluate the need for continuing education in this area.
Methods
An online survey tool was used to query participants regarding their approach to the diagnosis and treatment of concussion patients.
A 22 question, multiple-choice survey was adapted and modified with permission from one previously used by Zonfrillo et al.
The survey asked participants about their management of concussion patients, including barriers to management, use of published guidelines, and referral patterns to specialists. The study was approved under exempt status by our Institutional Review Board.
A total of three s containing a link to the multiple-choice survey were sent to all members of our local AAP chapter between January 2015 and June 2015.
Potential participants included primary care pediatricians and subspecialists, but subspecialists were excluded from our data analysis.
Of the 95 primary care pediatricians who responded, 52 were in private practice, 36 were hospital-based, and 1 worked in an urgent care center. 6 participants did not answer the question.
14 respondents completed medical school 0-4 years ago, 8 respondents 5-9 years ago, 8 respondents years ago, 3 respondents years ago, and 37 respondents 20+ years ago. 25 participants did not answer the question.
Conclusions
Most pediatric providers care for patients who have suffered a concussion; however, many identify barriers to diagnosis and treatment, which results in most providers referring some or all of their patients to subspecialists for further care.
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.