To determine the self-reported practices and attitudes surrounding concussion diagnosis and management in a single, large pediatric care network.
A cross-sectional survey was distributed to pediatric primary care and emergency medicine providers in a single, large pediatric care network. For all survey participants, practices and attitudes about concussion diagnosis and treatment were queried.
There were 145 responses from 276 eligible providers, resulting in a 53% response rate, of which 91% (95% confidence interval [CI]: 86%–95%) had cared for at least 1 concussion patient in the previous 3 months. A Likert scale from 1 “not a barrier” to 5 “significant barrier” was used to assess providers’ barriers to educating families about the diagnosis of concussion. Providers selected 4 or 5 on the scale for the following barriers and frequencies: inadequate training to educate 16% (95% CI: 11%–23%), inadequate time to educate 15% (95% CI: 12%–24%), and not my role to educate 1% (95% CI: 0.4%–5%). Ninety-six percent (95% CI: 91%–98%) of providers without a provider decision support tool (such as a clinical pathway or protocol) specific to concussion, and 100% (95% CI: 94%–100%) of providers without discharge instructions specific to concussion believed these resources would be helpful.
Although pediatric primary care and emergency medicine providers regularly care for concussion patients, they may not have adequate training or infrastructure to systematically diagnose and manage these patients. Specific provider education, decision support tools, and patient information could help enhance and standardize concussion management.
Comments
A Co-Management Approach to Increase Pediatric Providers' Capacity to Manage Conditions Such As Concussion
To the Editor:
The recent article "Pediatric Providers' Self-Reported Knowledge, Practices, and Attitudes about Concussion" by Zonfrillo et al. presented the results of a survey on the practices and attitudes of pediatric primary care providers (PCPs) and emergency medicine (EM) providers regarding concussion diagnosis and management. The authors concluded that, although PCPs and EM providers frequently care for patients with concussion, they may lack the training, infrastructure, and decision support tools required for systematic diagnosis and management of the condition. The study brings to light the very issues that we have been addressing through a structured Co-Management model at Connecticut Children's Medical Center and our network of community-based referring providers.
In our Co-Management model, a PCP-subspecialist dyad collaboratively develop a set of tools designed to support PCPs in providing standardized, evidence-based care for patients with relatively common conditions such as concussion. Each Co-Management tool-kit includes a standardized clinical algorithm, diagnostic and management tools such as symptom surveys and medication usage sheets, initial and follow-up visit forms to be completed by PCPs, a specialist feedback form to be completed by a specialist and sent to the PCP following a visit with a referred patient, and handouts for patients/families on the proper management of the condition. PCP- subspecialist dyads also develop continuing medical education (CME) presentations for community PCPs on the core competencies needed for Co- Management. Each subspecialist co-author discusses evaluation, management, and treatment of the condition, and each PCP co-author presents 1-2 case studies that demonstrate the use of the Co-Management plan components. Our pilot study demonstrated the feasibility of implementing this model for four conditions (pediatric voiding dysfunction, migraine, hematuria, and chronic fatigue syndrome/fibromyalgia). PCPs who implemented the model indicated that they were highly satisfied with the tools provided as part of the Co-Management model and felt that the CME training increased their preparedness to manage the condition(s). We are currently conducting a larger study evaluating the impact of Co-Management on the quality and cost of care for concussion, obesity co-morbidities, migraine, and pediatric voiding dysfunction.
The Co-Management model is particularly timely in the current environment of healthcare as it is a valuable resource for the implementation of the patient-centered medical home and accountable care. In order to achieve broad adoption of Co-Management by PCPs, there is a need for investment in infrastructure capable of supporting the model. We believe that an integrated health care system which has appropriate incentives for the provision of high-quality, cost-effective care will make the model increasingly attractive to hubs of pediatric primary care and subspecialty providers.
Conflict of Interest:
None declared