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Pediatric Concussions Undercounted; Most Don’t Present at EDs

PHILADELPHIA – While some children who suffer concussions — primarily those who are younger and covered by Medicaid — end up in the emergency department, the vast majority do not, according to a new study.

More than 82% of children in a study recently published in JAMA Pediatrics had their first concussion visit in a primary care setting, while 11.7% presented to an ED. Another 5% sought specialty care (sports medicine, neurology, trauma), and 1% were directly admitted to the hospital, according to the report.

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The problem, according to a study team involving researchers from the Children’s Hospital of Philadelphia (CHOP) and the national Centers for Disease Control and Prevention in Atlanta, is that counts of concussion injury among children often are solely based on ED visits or on organized high school and college athletics data.

The result likely is an undercount of the incidence of concussions.

"We learned two really important things about pediatric concussion healthcare practices," recounted lead author Kristy Arbogast, PhD, co-scientific director of CHOP's Center for Injury Research and Prevention. "First, four in five of this diverse group of children were diagnosed at a primary care practice — not the emergency department. Second, one-third were under age 12, and therefore represent an important part of the concussion population that is missed by existing surveillance systems that focus on high school athletes."

Noting that concussion diagnosis is symptom-based and does not require advanced diagnostic tools such as imaging, the researchers sought to gain a better understanding of who treats children with the condition to more accurately target training and resources.

For the study, the investigative team used CHOP’s electronic health record system to describe the healthcare point of entry for concussion from 2010 to 2014. The network includes more than 50 locations throughout southeastern Pennsylvania and southern New Jersey, including 31 primary care centers, 14 specialty care centers, an inpatient hospital, two EDs, and two urgent care centers, that support more than 1 million annual visits.

During that time period, 8,083 children ages 17 years and younger — median age 13 years, mostly white, and with private insurance — had an initial in-person clinical visit for concussion. While 52% of children up to age 4 years were taken to the ED, more than three-quarters of the patients 5 to 17 years old initially visited a primary care provider. The ED also was used more often for concussion care if children were covered by Medicaid, according to the results.

"Efforts to measure the incidence of concussion cannot solely be based on emergency department visits, and primary care clinicians must be trained in concussion diagnosis and management," the study concludes.